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College  of  logicians  ano  burgeon* 


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TREATISE 


ON 


ORTHOPEDIC  SURGERY 


BY 

EDWARD   H.  BRADFORD,  M.D. 

Surgeon  to  the  Children's  Hospital  and  to  the  Samaritan  Hospital ;  Assistant  Professor  of 
Orthopedic  Surgery,  Harvard  Medical  School 


ROBERT   W.  LOVETT,  M.D. 

Assistant  Surgeon  to  the  Children's  Hospital ;  Surgeon  to  the  Infants'  Hospital 


ILLUSTRATED    WITH    SIX    HUNDRED    AND    TWENTY-ONE    ENGRAVINGS 


Second   Revised  Edition 


NEW  YORK 
WILLIAM    WOOD   AND   COMPANY 

MDCCCXCIX 


Copyright,  1899, 
By  WILLIAM  WOOD  AND  COMPANY 


THE    PUBLISHERS'     PRINTING   COMPANY 
Si-34  LAFAYETTE  PLACE,   NEW  YORK 


TREATISE 


ON 


ORTHOPEDIC  SURGERY 


EDWARD   H.  BRADFORD,  M.D. 

Surgeon  to  the  Children's  Hospital  anil  to  the  Samaritan  Hospital  ;  Aesfetaot  Professor  of 
Orthopedic  Surgery,  Harvard  Medical  School 


ROBERT   W.  LOVETT,  M.D. 

Assistant  Surgeon  to  the  Children's  Hospital ;  Swqgeon  to  the  Infante'  Hospital 


ILLUSTRATED    WITH    Sl£<    HUNDRED    AN©    TWENTY-ONE    ENGRAVINGS 


Second   Revised  and   Enlarged   Edition 


NEW  YORK 
WILLIAM    WOOD   AND   COMPANY 

MDCCCXCIX 


Copyright,  1899, 
By  WILLIAM  WOOD  AND  COMPANY 


THE    PUBLISHERS'    PRINTING   COMPANY 
32-34  LAFAYETTE  PLACE,   NEW  YORK 


PREFACE. 


The  progress  of  orthopedic  surgery  in  the  last  nine  years  has  been 
so  rapid  that  a  revised  edition  of  this  work  has  necessitated  very  largely 
the  rewriting  of  the  entire  book.  But  few  changes  in  its  scope  or  classi- 
fication have  been  made ;  some  subjects,  however,  treated  in  the  former 
book  have  been  omitted  while  others  have  been  more  fully  considered. 
We  are  indebted  to  many  of  our  friends,  especially  to  our  fellow-members 
of  the  American  Orthopedic  Association  and  to  the  managers  of  the  Chil- 
dren's Hospital,  for  the  use  of  their  illustrations. 

Edward  H.   Bradford. 

Robert  W.   Lovett. 
Boston,  September,  1899. 


347518 


TABLE  OF  CONTENTS. 

PAGE 

Preface, -  •         •     in 

$                                      CHAPTER   I. 
Pott's  Disease, ■*• 

CHAPTER   II. 
Lateral  Curvature  of  the  Spine, * 

CHAPTER   III. 
Otheij  Affections  of  the  Spine,        ......•••   141 

CHAPTER   IV. 
The  Pathology,  Etiology,  and  Course  of  Chronic  Joint  Disease,      .         „  165 


CHAPTER   V. 


Hip  Disease, 


205 


CHAPTER   VI. 
Other  Diseases  of  the  Hip-Joint, 296 

CHAPTER   VII. 
Tumor  Albus  of  the  Knee-Joint, 308 

CHAPTER   VIII. 
Other  Diseases  of  the  Knee-Joint, 336 

CHAPTER   IX. 
Diseases  of  the  Joints  of  the  Ankle  and  Foot, 353 

CHAPTER   X. 
Diseases  of  the  Other  Joints, •  363 


CHAPTER   XI. 


Club-Foot, 


380 


CHAPTER   XII. 
Congenital  Dislocations, 427 

CHAPTER   XIII. 
Infantile  Spinal  Paralysis, 450 

CHAPTER   XIV. 
Cerebral  Paralysis  of  Children, 488 


Vi  TABLE   OF   CONTENTS. 


CHAPTER   XV. 
Pseudo-Htpertrophic  and  Other  Paralyses, 507 

CHAPTER  XVI. 
Functional  Affections  of  the  Joints,      .         .         .         .         .  .         .  617 

CHAPTER   XVII. 
Rickets, 527 

CHAPTER   XVIII. 
Knock-Knee  and  Bow  Legs,        ..........  546 

CHAPTER   XIX. 
Torticollis, 579 

CHAPTER   XX. 
Unilateral  Atrophy  ano  Hypertrophy, 595 

CHAPTER    XXI. 
Talipes  Equinds  and  Talipes  Calcaneus, 598 

CHAPTER   XXII. 
Flat-Foot  and  Other  Affections  of  the  Feet, 605 


ORTHOPEDIC    SURGERY. 


CHAPTER  I. 
POTT'S    DISEASE. 


Definition. — History. — Pathological   Anatomy. — Occurrence   and  Etiology. — Symp- 
toms.— Diagnosis. — Differential  Diagnosis. — Prognosis. — Treatment. 

Definition. — Pott's  disease  is  the  name  applied  to  a  destructive  patho- 
logical process  which  attacks  the  bodies  of  the  vertebrae.  The  other  names 
by  which  the  affection  is  known  are  as  follows :  Spondylitis,  Malum  Pottii, 
Caries  of  the  spine,  Kyphosis,  Angular  curvature,  Tuberculosis  of  the 
vertebras,  and  Spinal  curvature.  In  German  it  is  known  as  Die  Pott'sche 
Kyphose,  Spitzbuckel,  Winkelformige  Knickung  der  Wirbelsdule,  and 
Tuberculose  Wirbelentziindung ;  in  French  as  Cyphose,  Mai  de  Pott,  and 
Mai  Vertebral. 

History. — Antero-posterior  curvature  of  the  spine  is  an  affection 
which  was  described  by  the  ancients,  and  was  known  to  Hippocrates  and 
Galen,  who  attributed  its  cause  to  tubercle  "within  and  without  the 
lungs."  Ambroise  Pare  wrote  of  it  and  used  a  metal  cuirass  in  its  treat- 
ment, but  it  was  not  until  the  time  of  Percival  Pott  in  1779  that  any 
accurate  description  of  the  disease  was  given.1  In  honor  of  that  surgeon 
the  disease  is  chiefly  known  by  his  name.  The  existence  of  the  disease 
in  prehistoric  times  in  North  America  is  evidenced  by  a  specimen  in  the 
Peabody  Museum,  Cambridge,  Mass. 

Pathological  Anatomy. 

Pott's  disease  represents  the  result  of  a  destructive  ostitis  affecting 
the  spongy  tissue  of  one  or  more  of  the  vertebral  bodies.  This  ostitis, 
so  far  as  we  now  know,  is  tuberculous  in  type  and  follows  the  same 
course  as  tuberculous  ostitis  occurring  at  the  epiphyses  of  the  long  bones, 
as  in  hip  disease,  tumor  albus,  etc. 

The  first  appearance  noticeable  to  the  naked  eye  on  examining  a  sec- 
tion of  a  diseased  vertebra  at  an  early  stage  of  the  disease  is  a  small 

'  Pott:  "Remarks  on  that  Kind  of  Palsy  Affecting  the  Lower  Limbs,"  etc..  Lon- 
don, 1779. 

1 


2  ORTHOPEDIC    SURGERY. 

hypera^mic  spot  in  some  part  of  the  spongy  portion  of  the  body  of  the 
vertebra,  generally  near  the  anterior  surface  of  the  body.  This  spot 
grows  larger  and  more  red  as  the  process  extends,  and  finally  the  centre 
becomes  opaque  and  grayish,  while  a  zone  of  hyperemia  surrounds  it. 
A  focus  of  tuberculous  ostitis  is  present.  If  this  process  extends,  the 
opaque  spot  becomes  larger,  and  finally  cheesy  degeneration  of  its  centre 
takes  place.  At  other  times  both  caseation  and  degeneration  into  tuber- 
culous pus  take  place,  and  a  localized  abscess  of  bone  exists,  probably 
encapsulated  in  a  membrane  of  inflammatory  tissue,  which  surrounds  the 


Fig.  1. 


-Pott's  Disease  Involving  the  whole  Dorsal   Region.     Prehistoric  Iudiau  remains. 
Museum,  Spec.  lT.&K.t 


(Peabody 


focus,  endeavoring  to  protect  the  surrounding  healthy  bone  from  the 
erosive  action  of  the  focus.  Microscopical  examination  shows  a  mass  cf 
tubercles  in  a  rarefied  spongy  bone  tissue,  and  in  the  tubercles  are  to  be 
found  tubercle  bacilli.  From  the  fact  that  these  characteristics  are  to  be 
found  in  nearly  all  the  specimens  examined,  the  affection  is  spoken  of  as 
tuberculous  ostitis. ' 

The  focus  of  tuberculous  material  may  either  be  absorbed  or  calcified, 
or,  as  happens  much  more  commonly,  the  ostitis  may  increase  until  it 
has  destroyed  a  large  part  or  the  whole  of  a  vertebral  body.     In  its 

'Ridlon:  Orth.  Trans.,  vol.  iv. 


>OTT  S    IMSKASK. 


course  of  enlargement  it  may  include  portions  of  bone,  the  nutrition  of 
which  is  cut  off  by  the  adjacent  inflammatory  destruction.  Such  por- 
tions necessarily  become  necrosed  and  with  caseous  matter,  granula- 
tion tissue,  and  the  products  of  inflammation  constitute  an  area  of 
altered  and  degenerated  structure  in  the  vertebral  body.  If  this  diseased 
area  has  become  large 
enough,  the  vertebral 
body  gradually  becomes 
incapable  of  sustaining 
as  much  pressure  as  be- 
fore. From  the  peculiar 
weight-bearing  function 
of  the  vertebral  column 
the  pressure  upon  each 
vertebral  body  is  always 
considerable  when  the  "»»._. 
vertebral  column  is  in 
the  erect  position.  If 
one  vertebral  body  is 
becoming    excavated,    a  i 

point  will  be  reached 
where  it  can  no  longer 
sustain  the  weight  but 
must  give  way  slowly 
or  suddenly.  A  for; 
ward  tilt  of  the  whole 
vertebral  column  above 
the  seat  of  disease  is 
then  inevitable,  with  a 
certain  amount  of  back 
ward  angular  deformity 
at  the  diseased  vertebra. 
This  is  the  mechanism 

of  the  production  of  the 
■,  L-l  '  fl  11  fig.  2.— Tuberculosis  of  Cervical  aiid  Upper  Dorsal  Vertebrae.  Tu- 
KllUCKle  in  tlie  DaCR.  berculous  areas  ln  anterior  portion  of  eight  vertebras.  Prevertebral 
It  is  in  brief  a  soften-  ligament  pushed  forward  opposite  largest  tuberculous  area  (begin- 
'  .  ning  abscess).  «,  Knuckle ;  b,  secondary  tuberculous  foci ;  c,  pil- 
ing and  crushing  Ol   one  mary  focus  ;  J,  secondary  tuberculous  foci.    (Nichols.) 

or  more  vertebral  bodies, 

and  a  giving  way  of  the  column  at  that  point  as  a  necessary  mechanical 

result. 

This  process  is  limited,  as  a  rule,  to  the  vertebral  bodies ;  the  trans- 
verse, articular,  or  spinous  processes  are  rarely  affected  secondarily  or 
primarily,  their  structure  of  hard  bone  apparently  protecting  them  from 
tuberculous  invasion. 


-A  ORTHOPEDIC    SURGERY. 

There  has  been  discussion  as  to  the  possibility  of  primary  tuberculous 
disease  of  the  intervertebral  cartilage,  some  authorities  affirming  its  im- 
possibility, and  denying  the  reliability  of  the  pathological  observations 
cited  as  proof  to  the  contrary.  The  facts  are,  that  the  intervertebral 
cartilage  between  the  diseased  vertebrae  becomes  fibrillated  and  disinte- 
grated and  disappears,  but  that  a  very  few  cases  have  been  reported  by 


FIG.  3.— Lower  Dorsal  Region.  One  in- 
tervertebral disc  destroyed.  Extension  of  Fig.  4.— Lower  Dorsal  Region.  Opposite  half  of  speci- 
process  backward  to  dura  and  formed  along  men.  Specimen  rested  on  knuckle  while  hardening,  so 
prevertebral  ligaments.  ■  Moderate  knuckle  that  gravity  extended  the  spine.  Marked  separation  of 
hardened  in  upright  position,  so  that  gravity  diseased  vertebras,  a,  Tuberculous  disease  beneath  pre- 
pressed  diseased  vertebra  together,  a.  Tuber-  vertebral  ligaments ;  b,  cavity  between  diseased  vertebra, 
eulous  softening.    (Nichols).  (Nichols.) 

reliable  observers  in  which  it  would  appear  that  the  cartilage  alone  was 
affected.  In  the  light  of  modern  pathology  these  observations  must  be 
questioned. 

Various  portions  of  the  vertebral  bodies  may  be  affected.  There  may 
be  two  or  more  foci  in  one  vertebra,  or  the  whole  body  may  be  equally 
affected;  the  disease  may  be  limited  to  one  spot,  forming  a  localized 
abscess  of  the  bone,  or  it  may  extend  so  as  to  involve  the  adjacent  verte- 
brae. If  the  disease  remains  limited  to  the  centre  of  the  vertebra,  but 
little  deformity  may  result.  Primary  disease  of  two  vertebral  bodies  in 
different,  non-adjacent  parts  of  the  spine  is  rare.  But  an  extensive 
destruction  of  two  or  more  adjacent  vertebrae  from  primary  disease  of 
one  may  be  said  to  be  the  rule  in  Pott's  disease.  In  some  instances  this 
destructive  process  may  be  limited  to  the  surfaces  of  a  large  number  of 
vertebral  bodies:  in  others  a  few  contiguous  vertebral  bodies  are  com- 


pott's  disease.  ■> 

pletely  destroyed.  The  number  of  vertebrae  involved  necessarily  varies; 
in  some  instances  the  bodies  of  twelve  or  even  more  have  been  destroyed, 
producing  a  deformity  which   involves  almost  the  whole  of  the   spinal 


b J 


Fig.  5.— Tuberculosis  of  Lower  Dorsal 
Region.  Large  area  of  tuberculous  soft- 
ening involving  two  vertebrae.  Inter- 
vertebral disc  destroyed.  Process  ex- 
tends forward  beneath  prevertebral 
ligaments  and  pushes  aorta  forward. 
Trocess  also  extends  backward  to  dura. 
«,  Beginning  abscess;  7j,  aorta;  c,  tuber- 
culous softening  of  vertebrae..   (Nichols). 


Fig.  6.— Lower  Dorsal  and  Upper  Lumbar. 
Tuberculous  softening  in  anterior  portion  of 
bodies  of  five  vertebrae.  Marked  knuckle. 
Portion  of  one  vertebra  pushed  backward  into 
spinal  canal,  but  does  not  produce  pressure 
upon  spinal  cord,  a.  Tuberculous  disease  of 
vertebra ;  b,  tuberculous  foci ;  c,  cord ;  d, 
fragments  of  bone  projecting  into  spinal  canal. 
(Nichols.) 


L— b 


Fig.  7.— Lower  Lumbar  Region.  Section  obliquely 
through  lumbar  vertebra  and  ilium  in  the  line  of  the 
ilio-psoas  muscle.  Small  tuberculous  area  in  lowest 
lumbar  vertebra.  In  pelvis  is  large  tuberculous  abscess 
in  sheath  of  ilio-psoas  muscle,  a,  Tuberculous  focus 
in  lumbar  vertebras;  b,  peritoneum  and  sheath  of 
ilio-psoas;  c,  abscess;  (7,  ilium.     (Nichols.) 


6 


ORTHOPEDIC    SURGERY. 


column.  A  superficial  ostitis  of  the  anterior  surfaces  of  the  bodies, 
without  involving  the  intervertebral  cartilages  or  impairing  the  weigh  t- 
bearing  function  of  the  vertebrae,  has  been  observed,  though  it  is  rare. 

Abscess. — "  In  a  considerable  portion  of  cases  of  tubercular  disease  of 
the  spine  no  abscess  is  recognized  during  life,  but  in  cases  seen  at  autopsy 
an  abscess  is  almost  invariably  found,  although  it  may  be  of  small  size. 
The  tubercular  material  early  pushes  up  the  prevertebral  ligaments  and 
forms  a  flattened,  soon  a  nodular  swelling  in  front  or  sometimes  to  one 
side  of  the  vertebrae.  The  contents  of  such  a  swelling  are  like  the  con- 
tents of  other  tuberculous  abscesses"  (Nichols).' 

In  certain  cases  the  formation  of  tuberculous  pus  is  a  characteristic  of 
the  disease  from  the  first,  and  in  these  cases  abscesses  are  apt  to  be  a 


Fig.  8.— Spine,  Lower  Dorsal  and  Lumbar  Region.  Extreme  knuckle.  Lower  ribs  rest  on  pelvis. 
( Change  in  angle  of  ribs  due  to  continued  deformity.  Calibre  of  spinal  canal  not  diminished,  rt,  Knuckle  ; 
no  narrowing  of  canal.    (Nichols.) 


conspicuous  feature.  The  tuberculous  pus  finds  its  way,  during  or  after 
the  destruction  of  the  body  of  the  vertebra,  into  the  surrounding  tissues 
and  gravitates  downward.  It  appears  usually  in  the  course  of  the  sheath 
of  the  psoas  muscle  when  the  disease  is  situated  in  the  lower  half  of  thf 
spine,  but  the  site  of  the  abscess  necessarily  depends  upon  the  place  of 
the  original  disease,  and  may  be  in  the  mouth— as  in  retropharyngeal 
abscess — in  the  neck,  in  the  axilla,  or  in  the  back,  lungs,  abdomen,  or 
groin.  The  contents  of  such  abscess  as  a  rule  contain  no  pyogenic 
bacteria. 

Paralysis.— In  certain  cases  meningitis  and  myelitis  are  present  in 


1  Nichols  :  Ortli.  Trans. 


»1.  xi.,p 


pott's  disease. 


the  cord  opposite  the  seat  of  disease,  accompanied  sometimes  by  what 
is  virtually  the  destruction  of  the  cord  at  that  point.  The  pathologi- 
cal condition  of  the  spinal  cord  and  its  membranes  in  the  paralysis 
accompanying  Pott's  disease  of  the  spine  has  been  extensively  studied. 
It  has  been  shown  that  the  paralysis  is  very  rarely  caused  by  direct 
pressure  of  bone,  as  it  is  uncommon  for  even  very  marked  deformities 
of  the  spine  to  narrow  the  spinal  canal 
to  any  great  extent.  Moreover,  pa- 
ralysis sometimes  occurs  before  there 
is  any  deformity,  and  it  often  recovers 
while  the  deformity  gets  worse.  Many 
cases  with  extreme  deformity  are  never 
paralyzed  at  all.  In  52  cases  collected 
from  literature  by  Schmaus  '  in  which 
autopsy    afforded    a    chance    of    deter- 


FIG.  9.— Lower  Dorsal  Region.  Extensive  tuberculous 
softening  involving  two  vertebra? ;  intervertebral  disc 
destroyed.  Knuckle  very  slight,  probably  because  the 
focus  was  in  the  centres  of  the  vertebral  bodies,  and 
laterally  destruction  was  not  complete,  a,  Tubercu- 
lous cavity,  involving  centres  of  bodies  of  two  vertebra'. 
(Nichols.) 


Fig.  10.— a,  Compressed  cord,  portion  re- 
moved for  examination ;  b,  tuberculous 
dura;  c,  cauda.    (Nichols.) 


mining  the  cause  of  the  paralysis,  compression  was  mentioned  as  a 
cause  in  only  39  cases ;  in  33  of  these  a  caseous  pachymeningitis  was 
noted.  In  6  bony  pressure  existed,  and  in  5  of  these  the  odontoid  proc- 
ess of  the  axis  was  dislocated.  In  only  1  was  kyphotic  displacement 
the  cause  of  the  pressure.  Kraske "  estimates  bony  pressure  as  the  cause 
in  two  per  cent  of  the  cases.  Autopsy  shows  that  in  cases  of  paralysis  the 
process  ordinarily  begins  as  an  external  pachymeningitis.     The  disease 


1  Schmaus  :  "  Die  Compression-Myelitis  der  Caries.  "  etc.,  Wiesbaden,  1890. 
4 Kraske:  Archiv  f.  klin.  Chir.,  vol.  lxi. 


8 


ORTHOPEDIC    SURGERY 


of  the  vertebrae,  by  contiguity  or  by  irritation,  causes  this  meningitis, 
and  there  may  be  a  deposit  of  inflammatory  material  in  the  dura,  a  conse- 
quent thickening  of  that  membrane,  and  compression  of  the  cord  by  this 
thickened  dura  at  the  point  of  irritation.  Compression  from  thickened 
meninges  must  therefore  be  classed  as  one  cause  of  paralysis.  This 
meningitis  is  generally  clearly  tuberculous  in  character.  Myelitis,  or 
better,  meningomyelitis,  however,  at  times  exists  from  an  early  stage  in 


—6 


Fig.  11.— Tuberculosis  of  Lower  Cervical  and  Upper  Dorsal  Regions;  from  Front.  Trachea  dislocated 
to  right,  large  vessels  to  left,  by  large  tuberculous  abscess,  a.  Larynx  ;  b,  trachea  laid  open  ;  c,  wall  of 
abscess ;  d,  wall  of  abscess ;  e,  aorta  laid  open.     (Nichols.) 

the  cord  itself.  This  is  not  to  be  demonstrated  as  tuberculous  by  the 
microscope.  Oppenheim  says  of  such  processes  :  "  We  observe  in  syphi- 
litic and  tuberculous  persons  a  form  of  myelitis  which  neither  clinically  nor 
anatomically  can  be  considered  specific,  and  yet  it  must  stand  in  some 
relation  to  the  infectious  process. "  J  This  meningomyelitis  is  followed, 
if  it  is  severe  enough,  by  ascending  and  descending  degenerations  in  the 
columns  of  the  cord.  (Edema  also  is  present,  at  first  apparently  non- 
inflammatory in  character  but  later  inflammatory.     This  also  must  be  a 

1  Oppenheim  :   "  Lehrbuch  der  Nerveukrankheiten,  "  p.  224. 


POTT  S    IMttKASK. 


9 


factor  in  producing  symptoms,  and  alone  explains  the  immediate  im- 
provement in  certain  cases  after  forcible  rectification  of  the  deformity. 
Thrombosis  and  embolism  of  spinal  vessels  must  be  accounted  as  pos- 


:)- > 


Fig.  12.— Spine  (Dorsal  Region) 
Cut  in  Vertical  Antero-posterior 
section.  Only  one-half  of  spine  is 
shown.  Early  tuberculous  spinal 
abscess  projecting  in  "front  and  to 
one  side  of  spine.  Seen  from  the 
front,  n.  Vertebral  column  ;  6, 
ribs;  c,  abscess.     (Nichols.) 


Fig.  14.— Complete  Absorption 
< if  Vertebral  Body.  (Warren  Mu- 
seum.) 


Fig.  13.— Spine  Seen  from  Front. 
Mid-dorsal  region.  Portions  of  ribs  at- 
tached. Small  tuberculous  abscess  pro- 
jecting on  either  side  of  the  spinal 
column,  a.  Ribs  ;  b,  lateral  abscess ;  c, 
lateral  abscess.    (Nichols.) 


Fig.  15. — Complete    Bony  Ankylosis 
(Warren  Museum.) 


sible  factors  in  contributing  to  the  disturbance  in  the  cord.  The  order  of 
changes,  as  formulated  by  Schmaus,  is  as  follows :  oedema,  diffuse  soft- 
ening, and  sclerosis.  If  the  myelitis  ceases,  it  leaves  a  certain  amount 
of  sclerosis  of  the  cord  at  the  seat  of  the  disease.     This,  again,  may  be 


10 


ORTHOPEDIC    SURGERY 


very  slight,  or  the  cord  may  be  reduced  to  a  fractiou  of  its  former  size, 
and  yet  serve  well  enough  to  transmit  healthy  nervous  impulses. 

But  meningitis  and  myelitis  and  oedema  are  not  the  only  causes  of 
compression  myelitis  in  this  disease,  although  the  common  ones.  There 
may  be  a  direct  strangulation  of  the 
cord  by  the  vertebral  arches,  obliterat- 
ing the  canal;  or  an  abscess  from  dis-  - 
eased  bone  may  be  a  source  of  pres- 
sure within  the  canal.  A ,  caseous 
deposit  from  the  vertebra?  and  a  loose 
piece  of  bone  have  been  found  as 
sources  of  pressure.  The  explanation 
of  the  paralysis  by  the  assumption  of 
a  tuberculous  myelitis  of  the  cord  is 
not  compatible  with  the  well-known 
tendency  of  the  paralysis  toward  re- 
covery.1 


I- 1!    Hi. — Abscess  in  Hi^li  Dorsal  Carias. 


Fig.  17.— Distortion  of  Aorta.  From  a 
case  of  spinal  caries  in  an  adult.  At  one 
point  marked  constriction  of  the  aorta. 
Angular  deformity  very  marked,  n,  Con- 
striction of  aorta.     (Copied  from  I) wight. I 


In  proportion  to  the  extent  of  the  disease  and  the  number  of  vertebrae 
involved,  an  angular  deformity  of  the  spine  may  be  present  to  any  extent.  - 
In  severe  cases  this  angular  deformity  leads  to  many  secondary  pathologi- 
cal changes.     The  shape  and  capacity  of  the  chest  are  necessarily  very  much 


"Spiller:  Johns  Hopkins  Hosp.  Bull.,  June,  18!)8. 
2  Bouchacourt :  Rev.  d'Orth.,  .May,  1895. 


POTT'S    DISEASE.  11 

altered,  and  the  ribs  sometimes  sink  into  the  pelvis.  As  a  result  of  these 
changes  in  chest  capacity,  hypertrophy  of  the  heart,  often  accompanied 
by  valvular  disease,  is  common.  In  examining  thirty  one  post-mortem 
specimens  of  Pott's  disease  in  adults,  Neidert '  found  hypertrophy  of 
the  heart  in.tweuty-four,  muscular  degeneration  of  the  walls  of  the  heart 
in  four,  and  mitral  stenosis  in  two.  The  aorta  may  be  distorted  as  a  re- 
sult of  the  deformity.  Thomas  Dwight  reports  a  case  in  which  its  coarse 
"  might  be  compared  to  an  S  lying  on  its  side,  with  the  ends  bent  strongly 
back  to  fit  around  the  prominence  of  the  spine."  2  Lannelongue:i  found  a 
very  marked  narrowing  of  the  calibre  of  the  aorta  in  many  cases.  Some- 
times it  was  reduced  even  to  a  mere  slit. 

A  cure,  however,  is  possible  even  in  cases  with  very  advanced  de- 
formity. This  cure  can  come  about  in  one  of  two  ways:  (1)  By  anky- 
losis between  the  surfaces  of  the  bodies  of  the  diseased  vertebrae — a  very 
slow  process,  which  requires  years  for  its  completion ;  (2)  by  the  deposit 
of  bone  in  the  inflammatory  material,  thrown  out  around  the  column  and 
by  the  action  of  the  formative  ostitis  which  accompanies  the  destructive 
process,  the  vertebral  column  is  supported,  as  it  were,  in  surrounding 
bone. 

Occurrence  and  Etioloov. 

Sex. — Sex  does  not  appear  to  be  an  important  factor  in  causing  Pott's 
disease,  though  statistics  vary  somewhat.  Gibney  found  in  2,455  cases, 
1,329  males  and  1,12(5  females.  Mohr  found  females  slightly  more 
numerous  than  males.  Fisher,  in  500  cases,  found  2G1  males  and  239 
females.  Taylor  in  412.  cases  found  234  boys  and  177  girls.  Of  294 
cases  treated  at  the  Children's  Hospital  there  were  152  boys  and  142 
girls.     Vulpius4  in  810  cases  found  53  per  cent  of  males. 

Age. — The  disease  is  more  common  in  childhood.  Mohr  found,  in  72 
cases,  that  the  disease  occurred  between  the  first  and  fifth  years  in  29 
per  cent;  between  the  sixth  and  tenth  years  in  22  per  cent;  between 
the  eleventh  and  fifteenth  years  in  22  per  cent;  between  the  sixteenth  and 
twentieth  years  in  16  per  cent;  and  above  the  twentieth  year  in  11  per 
cent.  Drachman  found  in  161  cases  41  per  cent  between  one  and  five 
years,  and  36  per  cent  between  five  and  ten  years.  The  oldest  patient 
was  seventy-seven  years  of  age,  and  the  youngest  eight  weeks.  Gibney 
found  that  87  per  cent  were  under  fourteen  j^ears  of  age;  7  per  cent 
between  fourteen  and  twenty ;  and  4  per  cent  over  twenty-one.  Taylor 
found  in  375  cases  that  226  were  under  five ;  68  between  five  and  ten ; 
and  24  between  ten  and  fifteen.5 


'Neidert:  Iuaug.  Diss.,  Munich.  1886. 

-Dwight:  Amer.  Jour.  Med.  Sciences.  January,  1897 

3  Rev.  de  Chir.,  August  10th,  1880,  p   071. 

«Archiv  f.  kliu.  Chir.,  Bd.  lviii..  Hft.'2. 

"New  York  Med.  Record.  Auffust  18th.  1881. 


12  ORTHOPEDIC    SURGERY. 

Localization. — Any  of  the  vertebrae  may  be  attacked,  but  iu  varying 
frequency.  Statistics  are  of  uncertain  value,  as  they  are  chiefly  based 
upon  autopsies,  and  therefore  are  most  commonly  from  adults.  Mohr, 
in  50  autopsies  of  caries  of  the  spine,  found  that  the  disease  is  most 
common  in  the.  thoracic  region  (33  in  5G  cases),  next  in  the  lumbar  re- 
gion (27  times),  and  next  in  the  neck, (12  times).  The  sacrum  was  dis- 
eased in  1  case.  As  there  are  more  dorsal  vertebra?  than  either  cervical 
or  lumbar,  it  is  natural  that  the  number  of  cases  of  dorsal  disease  should 
be  greater  than  in  the  other  regions.  Bollinger  in  538  cases  determined 
the  vertebrae  originally  affected  to  be  as  follows:  cervical,  63;  dorsal, 
321;  lumbar,  154.  The  most  frequent  seat  was  between  the  twelfth 
dorsal  and  first  lumbar.  The  twelfth  dorsal  was  affected  64  times,  the 
first  lumbar  59  times,  and  both  123  times.  The  upper  half  of  the  column 
was  affected  primarily  only  117  times. 

Taylor  found  in  an  examination  of  three  hundred  living  patients  with 
Pott' s  disease  that  the  points  of  greatest  liability  to  the  disease  are  first,  the 
sixth  and  the  seventh  cervical ;  second,  near  the  eighth  dorsal ;  third,  the 
second  and  the  third  lumbar.  The  points  of  least  liability  to  the  disease 
are  from  the  first  to  the  fourth  dorsal  and  the  eleventh  and  the  twelfth 
dorsal,  besides  the  two  extremities  of  the  spinal  column.  Although,  as 
is  seen,  the  locations  of  relative  frequency  given  by  the  different  obser- 
vers do  not  agree,  it  would  appear  that  certain  portions  of  the  spine  are 
more  liable  to  attack  than  certain  others,  and  that  the  theory  advanced 
by  Taylor  was  a  plausible  one — viz.,  that  the  regions  most  liable  to  the 
disease  were  those  which  were  the  most  exposed  to  jars  or  increased  press- 
ure ;  and  that  the  disease  would  be  more  frequent  where  the  hinges  of 
motion  at  the  spinal  column  came,  varying  to  a  degree  according  to  age 
and  occupation,  or  where  there  was  the  greatest  exposure  to  the  effects  of 
violent  jars. 

Causation. — It  may  thus  be  assumed  that  the  localizing  cause  of 
Pott's  disease  is  jar  or  superincumbent  pressure;  the  influential  cause 
that  physical  state  which  is  incapable  of  resisting  slight  trauma,  expos- 
ing the  tissue  probably  to  the  invasion  of  the  tubercle  bacillus. 

Gibney,  in  an  examination  of  185  cases,  found  a  hereditary  tuber- 
culous taint  in  76  per  cent.  In  45  per  cent  a  weakened  condition  from 
previous  sickness  was  found;  and  in  22  per  cent  both  an  inherited  and 
an  acquired  diathesis  were  found.  Taylor,  in  845  cases,  found  53  per- 
cent with  a  history  of  preceding  trauma  (Vulpius  in  810  cases  found  the 
same  percentage  [53]) ;  in  15  per  cent  there  was  disease  of  the  lungs  in 
nearer  or  more  distant  relatives;  in  19  per  cent  so-called  scrofula  was  as- 
serted, and  in  34  per  cent  a  sickly  condition.  Vulpius  found  a  history  of 
hereditary  tuberculosis  in  16  per  cent  of  his  810  cases. 


pott's  disease.  13 


Symptoms. 

Pew  affections  have  a  clinical  history  which  varies  so  widely  and 
appears  under  such  different  guises  as  that  of  Pott's  disease.  The  one 
constant  symptom,  however,  which  accompanies  all  cases  of  Pott's  dis- 
ease and  must  often  form  the  chief  reliance  in  diagnosis  is  muscular 
rigidity  at  the  affected  portion  of  the  spine.  Just  as  spasm  of  the  joint 
muscles  is  the  constant  symptom  of  chronic  joint  disease,  so  is  restricted 
motion  between  the  diseased  vertebrae  the  constant  accompaniment  of 
Pott's  disease,  in  its  early  or  later  stages. 

Typical  cases  of  Pott's  disease  are  so  characteristic  in  their  symptoms 
that  the  diagnosis  is  evident  almost  at  a  glance.  The  guarded  character 
of  all  the  movements  is  perhaps  the  most  striking  feature.  In  walking. 
in  stooping,  or  in  lying  down,  the  spine  is  most  carefully  guarded  against 
jar  and  against  motion,  attitudes  are  assumed  which  relieve  the  vertebral 
column  of  some  of  the  weight  of  the  body,  and  a  glance  at  the  naked 
child  shows  unnatural  modes  of  standing  and  walking. 

A  prominence  of  the  vertebrae  is  ordinarily  present  as  early  as  at  this 
stage,  and  oftener  than  not  pain  is  acute  and  aggravated  by  motion. 
Constitutional  disturbance  is  also  very  likely  to  be  present  when  the  dis- 
ease has  been  of  even  a  few  weeks'  duration.  Loss  of  flesh  and  appetite 
and  inability  to  go  about  much  without  fatigue  are  often  among  the  first 
symptoms  to  attract  attention. 

Peculiarity  of  attitude  and  gait,  muscular  stiffness,  and  referred 
pain  are  the  most  prominent  of  the  earlier  symptoms,  and  they  may 
be  present  before  a  projection  has  been  noticed.  The  importance  of 
recognizing  these  early  symptoms  can  hardly  be  overstated,  as  it  is 
on  an  early  recognition  of  the  affection  that  the  hope  of  a  ready  cure 
is  to  be  based. 

Attitude. — The  peculiarity  in  attitude  noticed  early  in  the  disease  is 
due  either  to  reflex  muscular  spasm — similar  to  that  seen  in  joint  disease 
— or  to  an  unconscious  effort  on  the  part  of  the  patient  to  prevent  jar  or 
any  increased  pressure  upon  the  affected  vertebral  bodies.  These  atti- 
tudes necessarily  vary  according  to  the  point  of  the  spine  attacked.  In 
disease  of  the  upper  cervical  region,  the  most  common  attitude  is  that  of 
wry-neck. 

When  the  disease  is  in  the  lower  cervical  or  upper  dorsal  region,  the 
chin  is  held  somewhat  raised,  to  balance  the  weight  of  the  head  on  the 
articular  facets,  suggesting  the  position  of  a  seal's  head  when  out  of 
water.  The  spinal  column  below  the  point  of  disease  is  abnormally 
straight,  and  in  some  instances  curved  slightly  forward,  while  in  the 
lower  dorsal  region  an  exaggerated  backward  projection  of  the  spinous 
processes  may  be  seen;  this  projection,  due  to  a  compensating  curve,  is 


14 


ORTHOPEDIC    SURGERY 


sometimes  so  marked  as  to  suggest  that  the  disease  has  attacked  another 
part  of  the  spine. 

In  the  middle  dorsal  region  the  attitude  to  be  noticed  most  frequently 


Fig.  18.— Attitude  in  Cerviail  Caries 
of  only  Moderate  Seventy. 


Fig.  20.— Attitude  Assumed  by  Children  with  Acuv 
Pott's  Disease,  and  in  Other  Cases  Necessitated  b* 
Psoas  Contraction. 


Fig.  19.— An  Occasional  Attitude  Assumed  in 
Acute  Pott's  Disease,  Especially  when  the  Dis-  Fig.  21.— Attitude  in  Severe  Port's  Disease  with 

ease  is  in  the  Cervical  Region.  Psoas  Contraction. 


I'OTT  S   DISEASE. 


15 


is  an  elevation  of  the  shoulders.  Temporarily;  a  slight  lateral  deviation 
of  the  spine  is  to  he  seen.  In  the  lumbar  region,  the  patients  in  the 
early  stage  frequently  will  be  noticed  to  lean  backward,  like  pregnant 
women  or  adults  with  large  abdomens.  A  peculiar  position  and  charac- 
teristic sidling  gait,  which  is  sometimes  seen  at  a  comparatively  early 
stage  of  disease  in  the  lower  dorsal  or  lumbar  region,  is  due  to  a  slight 
contraction  of  the  psoas  and  iliacus  muscles. 

In  a  late  stage,  when  psoas  abscess  is  present,  a  marked  contraction 
of  these  muscles  takes  place;  but  even  when  there  is  no  evidence  of  ex- 


Fic-i.  "-i^.— Severe  Grade  of  Psoas  Contraction. 


Fig.  33.— Lordosis  in  Lumbar  Pott's  nisease. 


istence  of  suppuration  or  of  a  psoas  abscess,  slight  inflammatory  irrita- 
tion of  the  muscles  will  produce  a  limitation  to  the  arc  of  extension  of 
the  thigh  on  the  trunk. 

In  general,  in  addition  to  the  square  position  of  the  shoulders,  the 
peculiar  position  of  the  head,  and  the  erect  attitude  of  the  upper  part  of 
the  spine,  which  prevents  the  superincumbent  weight  of  the  trunk  and 
upper  extremities  (above  the  diseased  portion  of  the  spine)  from  falling 
forward  upon  the  diseased  vertebral  body,  the  gait  is  peculiar ;  the  pa- 


10 


ORTHOPEDIC   SURGERY. 


tient  walks  more  on  the  toes  than  on  the  heels,  and  with  thb  knees 
slightly  bent — in  such  a  way  that  all  possible  springs  may  be  brought 
into  play  to  diminish  jarring  the  spine. 

These  peculiarities  of  attitude  and  position  vary  in  severity  according 
to  the  acuteness  of  the  disease ;  they  may  be  at  one  time  more  noticeable 
than  at  another.  Characteristic  also  at  this  stage  of  the  disease  is  a 
muscular  stiffness,  which  becomes  more  marked  after  the  patient  has 
been  quiet  for  a  while  (during  sleep).  The  stiffness  of  the  limbs  dimin- 
ishes or  disappears  after  the  patient  has  moved  about.  A  certain  amount 
of  muscular  rigidity  of  the  muscles  of  the  back   will    be    felt  on    pal- 


Fig.   24.— Lateral  Deviation  of  Spine  in 
Dorsal  Pott's  Disease.    Front  view. 


Fig.  25.— Lateral    Deviation  of  the  Spine  in 
Dorsal  Pott's  Disease.    Back  view. 


pation  in  affections  of  the  middle  dorsal  and  lumbar  regions;  stoop- 
ing which  involves  arching  of  the  back  forward  is  difficult  or  impossible 
in  disease  of  the  lower  spine,  and  in  attempting  to  stoop  in  order  to 
pick  up  any  article  from  the  floor  the  patient  will  keep  the  spine  erect 
and  reach  the  floor,  lowering  himself  with  an  erect  trunk,  by  bending 
the  knees. 

It  will  often  be  noticed  that  children  become  tired  more  easily  than 
usual,  and  after  playing  about  for  a  time  will  desire  to  lie  down,  to  rest 
their  arms  upon  a  chair  or  seat,  or  to  support  the  head  with  their  hands, 
or  the  trunk  by  holding  on  to  the  thighs,  according  to  the  part  of  the 
spine  affected. 


POTT  S   DISEASE. 


17 


The  amount  of  muscular  stiffness,  rigidity,  and  difficulty  in  maintain- 
big  the  spine  erect  is  in  a  measure  an  index  of  the  degree  of  activity  of 
the  disease.  In  early  cases  the  muscles  on  either  side  of  the  area  of  the 
affected  vertebrae  will  often,  on  bending  the  back,  be  seen  to  spring  out 
in  relief,  acting  like  physiological  splints  to  the  diseased  vertebral 
column. 

Various  modifications  of  characteristic,  attitudes  are  at  times  produced. 
The  most  common  of  these  probably  is  the  flexion  of  the  thigh  which  re- 


Fic;.  26.— Lateral  Deviation  of  Spine,  in  Lumbar  Pott's 
Disease. 


Fig.  27.— Hounded  Outline  of  Deformity 
as  Seen  in  Cured  or  Convalescent  Pott's 
Disease. 


suits  from  psoas  contraction,  usually  the  result  of  psoas  abscess.  The 
contraction  of  the  muscle  is  both  the  warning  and  the  accompaniment  of 
the  abscess.  It  may  be  present  to  such  a  degree  that  the  leg  cannot  be 
put  to  the  ground  in  walking  and  the  use  of  a  crutch  is  necessitated. 

Lateral  deviation  of  the  spine  is  an  attitude  to  be  found  in  Pott's  dis- 
ease and  is  discussed  in  its  relation  to  lateral  curvature  under  the  head  of 
2 


IS  ORTHOPEDIC    SURGERY. 

diagnosis.  As  a  rule  the  lateral  curve  of  Pott's  disease  is  characterized 
by  very  slight,  if  any,  rotation  of  the  spinal  column  on  a  vertical  axis.  ■ 

The  lateral  deviation  has  no  especial  significance  except  in  indicating 
a  certain  modification  of  treatment  to  be  considered  later.  It  is  most 
severe  in  acute  cases.  The  divergence  may  reach  8°  from  the  perpen- 
dicular at  its  maximum  point, '  and  in  thirty  cases  measured  by  the  writ- 
ers did  not  exceed  this,  5°  makes  a  divergence  enough  in  amount  to 
make  the  fitting  of  apparatus  difficult.  This  divergence  is  diminished 
by  the  recumbent  position.  It  is  sometimes  the  first  symptom  of  Pott's 
disease,  and  one  which  has  attracted  but  little  attention. 

Pain. — In  certain  cases  of  Pott's  disease  pain  is  absent  altogether, 
but  it  is  often  present  to  a  most  distressing  degree,  and  it  forms  a  more 
prominent  symptom  than  it  does  in  hip  disease  or  tumor  albus,  for  in- 
stance. In  a  measure  it  tends  to  mislead  both  parents  and  physician, 
for  the  pain  is  rarely  complained  of  in  the  back,  but  is  referred  to  the 
peripheral  ends  of  the  nerves,  and  is  thus  described  as  being  felt  in  the 
abdomen,  chest,  or  limbs.  Chipault  has  described  a  class  of  cases  in 
which  severe  pain  in  the  kyphus  is  present,  and  has  given  to  the  con- 
dition the  name  "  apophysalgie  Pottique. "  3  Abdominal  pain  passes  for 
"  stomach-ache, "  and  pains  in  the  limbs  for  "  growing  pain  "  or  rheuma- 
tism. In  general,  it  may  be  said  here  that  persistent  localized  pain  in 
the  case  of  a  child  is  a  symptom  demanding  very  great  attention. 

The  sleep  of  these  children  is  apt  to  be  much  disturbed  by  pain,  for 
the  suffering  from  Pott's  disease,  like  all  the  pain  of  bone  diseases,  is 
more  severe  at  night.  In  the  milder  cases  this  is  manifested  by  simple 
restlessness,  while  in  more  severe  cases  it  takes  the  form  of  crying  spells. 
This  may  even  be  the  case  when  the  children  can  walk  about  without 
pain  during  the  day.  As  a  rule  the  pain  is  aggravated  by  exercise,  jars, 
and  wrenches.  It  is  not  always  elicited  by  pushing  down  on  the  child's 
head.  Superficial  sensitiveness  over  the  spinous  processes  is  not  a  symp- 
tom of  Pott's  disease. 

The  pain  is  usually  subacute,  and  may  be  only  occasional.  At  times 
the  attack  may  be  very  severe,  accompanied  by  intense  hypersesthesia, 
so  that  the  pressure  of  the  bedclothes  cannot  be  tolerated,  and  patients 
in  this  condition  have  been  supposed  to  have  intense  peritonitis  or  pleu- 
risy. The  subacute  form  is  more  common,  and  this,  together  with  mus- 
cular stiffness,  often  gives  rise  to  a  diagnosis  of  rheumatism,  sciatica,  or 
neuralgia.  Analogous  to  these  attacks  of  pain  are  disturbances  of  the 
functions  of  other  nerves — manifested  in  cough,  a  peculiar  grunting 
respiration,  dyspnoea  with  cyanosis,  gastric  disorders,  obstinate  and  re- 
curring vomiting,  and  troubles  of  the  bladder,  with  or  without  pain  at 


Annals  of  Surgery,  July,  1889.  2  Orth.  Trans.,  iii.,  182. 

3"Trav.  de  Neurologie  Ckir.,»  1898. 


pott's  disease. 


L9 


the  end  of  the  penis.  Patients  suffering  in  this  way  have  been  treated, 
for  bronchitis,  pneumonia,  gastritis,  or  cystitis.  In  one  notable  instance 
the  operation  for  stone  in  the  bladder — lateral  cystotomy — was  performed. 
No  vesical  trouble  was  discovered,  but  at  the  autopsy  disease  of  the  lum- 
bar vertebrae  was  found. 

These  periods  of  suffering  may  become  intense — constituting  acute 
attacks,  subsiding  after  rest,  and  recurring  at  intervals  without  apparent 
exciting  cause. 

Eye  symptoms  may  exist  in  Pott's  disease.  Partial  dilatation  existed 
in  thirty-six  out  of  thirty-eight  cases  reported  by  Bull,  and  neuritis  and 
optic  atrophy  have  been  reported. ' 

It  is  to  be  expected  that  pain  will  be  diminished  and  generally  con- 
trolled by  efficient  mechanical  treatment.  Certain  cases,  however,  are 
from  the  first  so  intractable  that  pain  persists  in  spite  of  all  that  can  be 
done.  Fortunately  such  cases  are 
not  the  rule,  and  in  general  it 
may  be  assumed,  when  pain  comes 
on  in  the  course  of  treatment,  that 
the  apparatus  does  not  fit,  if  me- 
chanical treatment  is  used,  or 
that  the  parents  are  not  careful 
in  the  nursing  of  the  child  .or  in 
carrying  out  treatment  thoroughly. 
In  a  few  instances  it  will  be  found 
that  pain  cannot  for  a  time  be 
entirely  checked  by  treatment. 
A  sudden  and  violent  increase  of 
pain  should  lead  one  to  suspect 
an  approaching  access  of  the  dis- 
ease— with  increase  of  the  de- 
formity'—  the  formation  of  an 
abscess,  or  the  beginning  of  pa- 
ralysis. In  cases  in  which  recov- 
ery from  Pott's  disease  has  oc- 
curred with  great  deformity  the 
lower  ribs  may  have  sunk  below  the 
crest  of  the  ilium,  and  by  rubbing 
against  it  may  cause  severe  pain. 

Deformity.  — The    most    char- 
acteristic feature  of  Pott' s  disease 

is  the  deformity — that  is,  the  projection  backward  of  one  or  more  spinous 
processes.     This  is  occasioned  by  the  destruction  of  the  vertebral  bodies. 


Fig.  28.— Sharp  Angle  of  the  Acute  Stage. 


1  Knies  :  "  Das  Sehorgan  unci  seine  Erkrankungen, "  1893,  p.  205. 


20 


ORTHO I ' BD 1 C    S U RGER Y. 


The  projection  is  primarily  of  the  vertebrae  first  affected,  but  follow- 
ing this  other  vertebrae  are  more  or  less  involved,  and  the  curve  in- 
creases, with  the  establishment  of  secondary  curves.  The  sharper  the 
projection,  as  a  rule,  the  more  acute  is  the  process;  but  this  rule,  how- 
ever true  in  the  upper  dorsal  region,  has  occasional  exceptions  in  the 
lower  dorsal  and  upper  lumbar  regions.  It  may  be  stated  that  in  old 
cases  there  is,  as  a  rule,  more  of  a  curve  and  less  of  an  angle.  It  is  nor 
absolutely  true  that  the  greater  the  amount  of  the  disease  the  greater  the 
deformity,  for  there  may  be  extensive  disease  on  the  front  of  several 


_      . 

Fig.  39.— Method  of  Measuring  Deformity  in  Pott's  Disease.    (Children's  Hospital  Report.) 

bodies  without  diminishing  the  weight-bearing  function  of  all  of  them ; 
but,  generally,  the  more  vertebras  involved,  the  greater  is  the  projection. 

It  is  most  important  to  keep  a  record  of  the  deformity  in  each  case 
under  observation.     This  record  is  most  easily  taken  by  a  simple  method. 

A  strip  of  sheet  lead  half  an  inch  wide,  of  the  quality  known  to  the 
dealers  as  "four  pounds  to  the  foot,"  is  made  straight  by  pressing  out 
the  curves,  and  is  laid  along  the  spinous  processes  of  the  child,  who  lies  on 
his  face  on  a  flat  table  without  a  pillow,  with  his  hands  at  his  sides,  and 
his  head  turned  to  one  side.  With  the  fingers  the  lead  is  pressed  against 
the  spinous  processes,  and  when  it  is  removed  it  is  stiff  enough  to  keep 
its  shape.  The  curve  is  then  drawn  upon  a  piece  of  cardboard  by 
means  of  this  lead  strip,  placed  on  its  side  and  used  as  a  ruler.  The 
cardboard  curve  is  cut  out  with  scissors  and  the  concavity  is  then  applied 
to  the  child's  back  to  see  if  it  fits  accurately.  If  not,  it  should  be 
trimmed  with  the  scissors  until  it  does.  The  slightest  change  in  the 
outline  of  the  back  can  then  be  detected  at  any  subsequent  visit,  because 
any  increase  or  diminution  of  the  deformity  will  cause  the  cardboard 
cutting  to  fit  the  outline  of  the  back  imperfectly. 

If  the  deformity  is  left  to  itself,  its  tendency  is  to  increase  until  a 


POTT  S    WSKASK. 


2  J 


spontaneous  cure  results  or  death  ensues.  In  many  cases  in  dorsal  Pott's 
disease  this  result  is  reached  only  after  an  enormous  deformity  has  oc- 
curred, hi  cervical  and  lumbar  Pott's  disease  spontaneous  cure  is  more 
likely  to  occur,  and,  when  it  occurs,  is  accompanied  by  much  less  de- 
formity than  in  the  dorsal  region. 

When  this  spontaneous  cure  occurs,  the  change  takes  place  gradually 
and  does  not  cause  narrowing  of  the  spinal  canal.  The  gibbosity  is  most 
marked  in  disease  of  the  upper  dorsal 
region;  the  curve  in  the  lumbar  region 
is  an  arc  with  a  longer  radius  than  is 
found  elsewhere  in  the  spine.  The  sec- 
ondary curvatures  are  :  in  cervical  Pott's 
disease,  a  dorsal  incurvation  below  the 
disease,  with  a  slight  lumbar  excurva- 
tion ;    in    dorsal    disease,   an   increased 


Fig.  30.  —Depression  of  the  Sternum  in  Dorsal  Pott's 
I  >isease. 


Fig.  31.— Showing  Shortening  of  Trunk  in 
Pott's  Disease  of  Moderate  Grade. 


hollowing  in  above  and  below  the  gibbosity  of  the  disease;  in  lumbar 
disease,  a  long  curvature  with  convexity  inward  above  the  disease.  The 
neck  becomes  shortened  and  thickened  in  cervical  Pott's  disease;  the 
trunk  is  shortened  in  disease  of  other  parts  of  the  spine;  there  is  also 
in  cases  of  long  duration  a  diminution  of  an  uncertain  origin  in  the 
growth  of  the  whole  body,  so  that  adults  recovered  from  Pott's  disease 
of  ordinary  severity  are  usually  of  less  than  average  height.  In  severe 
cases  the  limbs  more  usually  grow  nearer  to  the  normal  amount,  and  are 
necessarily  out  of  proportion  to  the  length  of  the  trunk. 


22 


ORTHOPEDIC    SURGERY. 


Taylor1  has  formulated  the    retardation  of  growth  in  patients  with 
Pott's  disease  as  follows : 

"  Disease  of  the  cervical  region  is  least  harmful  in  this  regard ;  dis- 
ease of  the  dorsal,  especially  the  lower  half,  the  most  so,  while  disease 
of  the  lumbar  .region  occupies  an  intermediate  position.  An  average 
growth  of  an  inch  to  an  inch  and  a  half, 
extending  over  a  number  of  years,  instead 
of  the  normal  two  inches  and  upward,  is 
fairly  satisfactory  for  patients  under  treat- 
ment or  soon  after  the  active  stage  of  the 
disease.  A  growth  of  one  and  one-half  to 
two  inches  for  a  similar  period  indicates 
that  disease  is  arrested  or  is  retrogressive ; 
in  other  words,  that  the  case  is  doing  well. 
Very  slow  or  absent  growth  indicates 
progressive  disease  or  impaired  vitality. 
Intercurrent  disease  or  too  long  absence 
from  surgical  supervision  is  often  followed 
by  a  diminution  of  the  growth  rate." 


Fig.  32.— Diagram  of  Abscess  from  Pott's  Disease. 


Fig.  33.— Lumbar  Abscess. 


An  alteration  in  the  shape  of  the  lower  part  of  the  face  takes  place  in 
marked  dorsal  disease,  with  a  facial  expression  which  is  characteristic. 

Cases  in  which  the  deformity  is  rapidly  increasing  are  as  a  rule  char- 
acterized by  much  pain. 

Deformity  of  the  chest  is  a  constant  accompaniment  of  dorsal  Pott's 
disease.  The  vertebral  column  cannot  give  way  and  form  an  angular  de- 
formity without  altering  the  position  of  the  sternum  and  ribs.     The  de- 


1  H.  L.  Taylor  :  Transactions  of  the  American  Orthopedic  Association,  xi.,  p.  197. 


pott's  disease.  23 

fortuity  is  usually  a  thrusting  downward  and  forward  of  the  sternum 
with  a  lateral  flattening  of  the  chest.  In  short,  it  results  in  the  forma- 
tion of  a  pigeon-breast.  There  may,  however,  be  a  prominence  of  the 
ribs  on  both  sides  of  the  sternum,  where  a  depression  of  the  sternum 
is  seen.  Sometimes  the  pigeon-breast  is  the  first  symptom  to  attract  the 
attention  of  the  parents,  and  for  that  alone  the  children  are  brought  to 
the  surgeon. 

High  temperature  is  generally  present  in  the  afternoon  in  cases  under 
ambulatory  treatment.  This  temperature  is  diminished  or  often  reduced 
to  normal  in  cases  under  bed  treatment.  The  rise  of  temperature  is  from 
one  to  three  degrees  in  average  cases  aud  occurs  independently  of  ab- 
scesses. This  statement  rests  on  ten  hundred  and  fifty  observations 
made  at  the  surgical  out-patient  department  of  the  Children's  Hospital.' 

*  General  Condition. — Pott's  disease  produces  a  more  profound  impres- 
sion upon  the  general  condition  than  do  the  other  tuberculous  joint  and 
bone  diseases.  These  children  are  frequently  fretful  and  capricious, 
made  so  either  by  the  disease  and  by  ill-health  or  by  injudicious  petting 
on  the  part  of  the  family.  They  are  also  often  precocious  and  their 
mental  development  is  superior  .to  that  of  healthy  children  of  the  same 
age.  They  are,  moreover,  delicate,  take  cold  easily,  and  seem  especially 
liable  to  slight  attacks  of  pneumonia.  Patients  with  Pott's  disease  are 
of  course  liable  to  attacks  of  tuberculous  meningitis,  but  the  experience  of 
the  writers  would  lead  them  to  believe  that  the  liability  to  this  was  less 
than  in  hip-joint  disease.  Necrosis  of  the  ribs  is  one  of  the  more  uncom- 
mon complications.   \ 

Complications. 

Paralysis. — Partial  or  complete  paralysis  of  the  legs  is  a  frequent 
complication  of  Pott's  disease.  It  may  occur  in  early  or  late,  in  mild  or 
severe  cases,  and  no  apparent  exciting  cause  can  be  assigned  for  its 
appearance. 

The  clinical  picture  is  what  one  would  expect  from  a  consideration  of 
the  pathological  condition ;  a  paralysis  of  motion  mild  or  severe,  followed, 
if  the  case  gets  worse,  by  more  or  less  paralysis  of  sensation.  The  motor 
paralysis  varies  from  mere  muscular  weakness  to  complete  loss  of  power. 
It  begins  as  a  sense  of  fatigue,  a  dragging  of  the  feet;  then  there  is  in- 
ability to  hold  one's  self  erect.  Unless  the  disease  is  in  the  lumbar 
region,  the  reflexes  are  exaggerated,  and  muscular  spasms  may  start  from 
the  least  irritation;  they  frequently  appear  spontaneously.  In  severe 
cases  the  muscles  are  flaccid  and  the  legs  may  be  powerless.  With  the 
secondary  degenerations  in  the  cord  rigidity  sets  in.  The  bladder  and 
rectum  are  paralyzed  toward  the  end  of  all  very  bad  cases,  and  whenever 

1  Artier.  Jour.  Med.  Sciences.  December.  1891. 


24  ORTHOPEDIC    SURGERY. 

the  lumbar  enlargement  is  involved;  in  milder  eases  they  escape.  The 
ainis  are  paralyzed  in  certain  instances  of  dorsal  Pott's  disease.  Of  the 
sensory  paralysis  below  the  lesion  there  is  less  to  be  said;  it  is  apt  to 
begin  as  paresthesia;  anaesthesia  afterward  may  come  on  to  a  greater  or 
less  extent.  Trophic  disturbances  are  not  to  be  seen  unless  in  excep- 
tional cases. 

The  wasting  of  the  muscles  and  diminution  of  electric  contractility 
are  usually  only  such  as  disuse  would  cause. 

In  a  few  instances  affections  of  the  joints,  supposed  to  be  secondary 
to  lesions  of  the  cord,  have  been  noted,  and  instances  are  mentioned  in 
which  herpes  zoster,  apparently  due  to  the  same  cause,  was  present. 

Many  patients  with  Pott's  disease,  especially  children,  are  bedridden, 
or  at  least  unable  to  go  about,  without  being  paralyzed.  In  these  cases 
the  reflexes  should  be  normal.  When  the  disease  runs  its  course  un- 
checked, asthenia  is  often  profound,  and  although  there  may  be  no  trace 
of  paralysis,  the  patient  frequently  has  no  desire  or  strength  to  walk  or 
even  to  sit  up.  Another  cause  which  sometimes  keeps  patients  off  their 
feet,  independently  of  paralysis,  is  psoas  contraction  of  a  severe  grade, 
especially  if  it  be  bilateral.  Still  another  reason  is  a  preponderating 
mental  impression  of  inability  to  walk  or  stand.  Many  patients  persist 
in  walking  when  paralyzed  to  a  degree  which  ought  to  preclude  it,  and 
which  would  ordinarily  do  so,  while  others  are  bedridden  with  little  or 
no  paralysis,  or  remain  so  after  the  paralysis  has  totally  disappeared, 
having  recovered  without  being  conscious  of  restoration.  This  accounts 
for  the  suddenness  of  invasion,  and  particularly  of  recovery,  in  some  of 
these  paralyzed  cases. 

Paralysis  is  rarely  an  early  symptom  in  Pott's  disease,  though  it  has 
been  observed  before  the  stage  of  deformity.  The  frequency  of  paralysis 
is  indicated  by  the  figures  collected  by  Gibney.  Among  295  patients 
with  caries  of  the  spine,  paralysis  was  noted  62  times;  in  189  cases  of 
caries  of  the  upper  dorsal  and  cervical  region,  paralysis  occurred  in  59 ; 
in  106  cases  of  lower  dorsal  and  lumbar  disease,  paralysis  occurred  in 
only  3.  In  700  cases  observed  by  Dollinger,  41  cases  of  paralysis  were 
noted;  4  of  these  were  in  the  cervical  and  37  in  the  dorsal  region.  In 
26  of  the  41  cases  the  disease  involved  the  region  from  the  third  to  the 
seventh  dorsal  vertebrae  inclusive. 

Paralysis  is  usually  bilateral;  it  may,  however,  be  unilateral,  and  in 
some  unusual  instances  it  occurs  above  the  point  of  deformity.  Taylor 
and  Lovett '  found  in  an  examination  of  59  cases  of  paralysis  (out  of  445 
cases  of  Pott's  disease)  that  the  location  of  disease  was  as  follows:  1  cer- 
vical, 7  cervico-dorsal,  37  dorsal,  7  dorso-lumbar,  4  lumbar,  3  unclassi- 
fied.    The  deformity  was  large  in  20,  medium  in  10,  small  in  17  (in  12 

'Med.  Rec,  ]88<i,  xxix  ,  699. 


pott's  disk  ask. 


unclassified).  The  paralyzed  eases  presented  no  worse  deformity  than 
that  seen  in  average  cases.  In  26  the  outline  of  the  deformity  was 
rounded  and  gradual;  in  1  10  it  was  distinctly  sharp.  The  paralysis  oc- 
curred on  the  average  about  two  years  after  the  beginning  of  the  disease. 
It  came  on  immediately  after  a  fall  in  4  cases.  The  duration  of  the 
paralysis  was  never,  in  the  cases  reported,  over  three  years,  except  in 
ime  case,  when  it  persisted  with  but  little  improvement  for  six  years;  in 
2  cases  it  lasted  three  years;  in  5  cases  it  lasted  two  years.  A  recur- 
rence of  the  paralysis  was  noted  in  <>  cases,  4  having  two  attacks  and  2 
having  three,  Recurrence  is  not  an  unusual  feature  in  its  history.  Out 
of  72  cases  of  caries  of  the  spine  watched  by  Mohr,  there  was  paralysis  in 
seven  per  cent. 

Paralysis  is  an  affection  of  rare  occurrence  in  Pott's  disease  under 
efficient  protective  treatment.  Its  prognosis  is  extremely  favorable  in 
mild  cases,  or  in  severe  ones  if  they  can  be  treated  early.  Kecovery, 
when  it  occurs,  is  generally  complete,  leaving  no  trace  of  the  disability 
of  the  limbs.  Incomplete  recovery  is  uncommon,  but  incomplete  paraly- 
sis often  is  present.  In  fact  the' early  commencement  of  efficient  treat- 
ment will  often  seem  to  render  abortive  an  attack  of  paraplegia,  and 
change  what  threatened  to  be  a 
complete  loss  of  power  to  a 
comparatively  trifling  disabil- 
ity which  is  merely  enough  to 
prevent  walking  for  a  few 
weeks  or  months. 

Abscess. — In  most  cases  of 
Pott's  disease,  especially  in 
those  under  efficient  treatment, 
the  whole  course  is  run  without 
any  evidence  of  suppuration, 
but  in  others  abscesses  form  a 
distressing  complication. 

The  earlier  treatment  is  be- 
gun and  the  more  efficiently  it 
is  carried  out,  the  less  liable 
are  abscesses  to  form;  but  it 
must  not  be  assumed  that  the 
occurrence  of  abscesses  is  evi- 
dence of  incomplete  treatment 
abscess  cannot  be  avoided. 

The  causes  of  the  development  of  an  abscess  are  the  same  in  Pott's 
disease  as  in  bone  tuberculosis  elsewhere.  What  the  abscess-determining 
influences  are,  which  in  some  instances  give  rise  to  profuse  suppuration, 
and  the  absence  of  which  in  other  cases  allows  immunity,  is  at  present 


Retropharyngeal  Abscess,  showing  Character- 
istic Expression  anil  Attitude. 


In  certain  cases  of  severe  disease  an 


26 


ORTHOPEDIC    SURGERY 


conjectural.  They  may  be  supposed  to  be  dependent  on  the  amount  of 
constitutional  or  local  power  of  resistance  on  the  part  of  the  patient;  the 
extent  of  the  bacillary  invasion;  the  severity  of  a  previous  injury;  and 
the  individual  degree  of  recuperative  power,  or  of  reparative  tissue  devel- 
opment. If  we  consider  the  situation  of  the  vertebral  bodies  (the  point 
of  origin  of  abscesses) — projecting  into  the  cavities  of  the  thorax  and 
abdomen,  surrounded  by  the  lungs  and  intestines,  close  to  the  large  ves- 
sels and  the  oesophagus — it  will  seem  extraordinary  that  the  formation-  of 
an  abscess  does  not  more  frequently  -lead  to  a  fatal  termination.  In  fact, 
however,  the  fluid  contents  of  the  abscesses  follow  in  the  line  of  least  re 
sistance,  and  the  layers  of  fasciae,  in  most  cases,  protect  the  larger  cavities 
of  the  trunk  from  invasion;  the  pus  generally  extends  to  the  surface  at 
points  distant  from  its  origin,  appearing  in  the  neck,  in  the  lumbar  region, 
in  the  groin,  or  in  Scarpa's  triangle.  Treves'  table  shows  the  anatomical 
conditions  affecting  the  course  of  abscesses. 


Variety. 


Cervical. 


Dorsal. 


Lumbar. 


Course. 

fa.  Anterior. 

b.  Burrow  beneath  deep  fascia  into 
-[      thorax  as  mediastinal  abscess. 
I  c.  Laterally    between    the    longus 
(_     colli  and  scaleni  muscles. 

(a.  Burrow  posteriorly. 

j  b.  Within  psoas  sheath. 

I 

(a.  Enter  psoas  sheath. 

|  b.  Burrow  between  the  fascia?  of  the 
quadratus  lumborum  and  ab- 
dominal muscles,  through  the 
internal  oblique. 

!  c.  Gravitate   beneath   the   internal 

j  iliac  muscles  over  the  posterior 
brim  of  the  pelvis,  perforating 
the  great  sacro-sciatic  foramen. 
d.  May  be  directed  to  the  iliac  re- 
gion along  the  aorta  and  external 

[_       iliac  arteries. 


Exit. 
Into  posterior  walls  of  pharynx. 
Into  trachea,  oesophagus,  or  through 

an  intercostal  space. 
Posterior  to  the  sterno-cleido-mas- 

toid. 

On  the  back  or  side  a  short  distance 

from  the  spine. 
Beneath    Poupart's    ligament     in 

Scarpa's  triangle. 

As  psoas  abscess. 

Posteriorly  beneath  the  external 
oblique  and  latissimus  dorsi  at 
the  outer  border  of  the  erector 
spinse  muscle. 

As  gluteal  abscess. 


As  gluteal  abscess. 


Of  these  psoas  abscess  is  the  most  common.  It  is  very  rarely  met 
'•with  in  children  unless  in  connection  with  vertebral  disease,  but  in  gen- 
eral it  is  an  almost  pathognomonic  sign  of  dorsal  or  lumbar  Pott's 
disease. 

The  abscess  tends  to  enlarge  more  on  its  outer  than  on  its  inner  sido 
because  the  fascia  is  less  resistant  there.  It  finally  reaches  Poupart's 
ligament  and  bulges  in  the  groin.     The  pus  may,  however,  travel  as  far 


pott's  DISEASE. 


27 


down  as  the  insertion  of  the  psoas  muscle.  There  is  then  a  swelling 
both  above  and  below  Poupart's  ligament,  and  fluctuation  may  be  de- 
tected between  the  two  by  placing  one  finger  above  the  ligament  and  the 
other  below  it. 

Pus  may  find  its  way  to  the  iliac  fossa  either  from  a  psoas  abscess  or 
by  finding  its  own  way  there  directly  from  the  diseased  bodies.  At  times 
a  collection  of  pus  will  work  over  the  crest  of  the  ilium  or  through  the 
sacro-sciatic  foramen  and  point  in  the  gluteal  region. 

A  lumbar  abscess  is  the  outcome  of  disease  of  the  lumbar  vertebrae 


Fig.  35.— Psoas  Abscess. 


It  appears  as  a  swelling  in  the  loin  on  one  side  or  the  other  just  outside 
the  quadratus  lumborum.  At  times  it  is  associated  with  dorsal  caries 
and  not  with  lumbar. 

Abscesses  may  accumulate  in  the  inguinal  region  above  Poupart's 
ligament,  simulating  hernia.  Before  passing  down  the  sheath  of  the 
psoas  muscle,  they  may  enlarge  in  the  abdominal  cavity  beneath  the 
peritoneum,  constituting  a  layer  of  subperitoneal  abscesses.  In  time 
these  abscesses  descend  down  the  thigh,  but  they  may  remain  for  a  long 
time  large,  threatening,  abdominal  tumors. 

Dollinger,  in  700  cases  of  Pott's  disease  observed,  found  154  abscesses. 
Of  cervical  cases  20.6  per  cent  resulted  in  abscess,  of  dorsal  cases  11.6 
per  cent,  and  of  lumbar  cases  40.1  per  cent.  In  the  154  abscesses  there 
were  13  cervical,  47  dorsal,  and  94  lumbar.     B.    W.   Parker  in  dorsal 


28 


OKTHOl'EDIC    SURGERY. 


cases  found  8  per  cent  of  suppuration,  in   dorso-lurabar  .'!<)  per  cent,  und 
in  lumbar  cases  7<»  per  cent. 

Abscesses,  however,  at  times  point  in  all  sorts  of  places.  They  may 
burst  into  tbe  mouth,  trachea,  bronchi, '  mediastinum,  oesophagus,  or 
pleura.  They  may  rupture  into  the  intestines,  bladder,  vagina,  rectum,  or 
the  abdominal  cavity ;  and  one  case  is  reported  in  which  a  spinal  abscess 
simulated  a  fistula  in  ano.  Abscesses  may  also  burst  into  the  spinal 
canal  or  the  hip-joint.  Occasionally  they  burst  in  the  alimentary  canal, 
not  so  rarely  in  the  lungs,  and  exceptionally  in  the  peritoneum  or  larger 

vessels.  Sometimes  apparently  the 
sac  descends  on  both  sides  of  the 
spinal  column,  developing  two  ab- 
scesses. 

The  local  symptoms  presented 
by  abscesses  vary  with  the  locality. 
Retropharyngeal  abscesses  cause  dys- 
pnoea and  dysphagia.  Abscesses  in 
the  lung  give  rise  to  less  disturbance 
than  would  be  supposed;  in  reality 
they  present  the  rational  and  physi- 
cal signs  of  a  low  form  of  localized 
pneumonia,  of  a  chronic  or  subacute 
type.  The  bursting  of  an  abscess 
into  the  bronchi  is  characterized  by 
the  discharge  of  a  large  quantity  of 
pus,  Avhich  is  coughed  up,  the 
amount  of  dyspnoea,  collapse,  and 
danger  from  suffocation  being  de- 
fig.  36.— cervical  Abscess.  pendent  on  the  size  of  the  abscess. 

The  sudden  discharge  of  pus  is  the 
indication  of  rupture  into  the  oesophagus,  intestines,  and  bladder;  rup- 
ture into  the  vessels  will  necessarily  be  fatal,  and  there  are  no  symptoms 
which  will  give  warning  of  the  impending  danger. 

The  course  of  an  abscess  is  toward  absorption  or  increase.  It  ma}r 
remain  stationary  in  size,  and  quiescent  for  a  long  time — a  condition  of 
things  which  may  be  compatible  with  fair  general  health.  Instances  are 
not  uncommon  in  which  adults  have  been  able  to  attend  to  active  work 
and  children  to  play  about,  although  suffering  from  large  cold  abscesses. 
When  absorption  takes  place  the  fluid  contents  disappear,  and  the 
caseous  and  purulent  detritus,  if  present,  in  all  probability  becomes 
encapsulated.  This  sometimes  happens  even  in  quite  large  psoas  ab- 
scesses. 


•Cossy:   Bull.  Soc.  Anat.,  1877,  .">41,  and  Gamlet :  Bull.  Soc.  Anat.,  1K78. 


pott's  disease.  29 

When  the  abscess  is  evacuated,  for  example  under  good  treatment, 
there  is  as  a  rule  but  slight  general  disturbance,  provided  it,  by  operation 
or  rupture,  opens  or  is  opened  in  such  a  way,  as  to  give  complete  drain- 
age; if  it  is  evacuated  only  in  part,  and  if  the  cavity  of  the  abscess  is 
large,  extending  upward  to  the  spinal  column  by  means  of  a  long  cir- 
cuitous channel  which  does  not  admit  of  complete  drainage,  fever,  with 
septic  changes,  usually  follows  the  evacuation  of  the  abscess,  varying 
in  different  cases  in  amount  and  extent. 

Leucocytosis  is  not,  however,  always  present  in  such  abscesses,  nor 
if  it  is  present  is  it  an  indication  that  pyogenic  bacteria  are  present  in 
the  abscess.1 

As  a  rule  abscesses  which  burst  externally  spontaneously  are  very 
likely  to  discharge  from  pouting  sinuses  for  an  indefinite  time,  often  for 
years.  This  tendency  seems  to  be  diminished  by  thorough  operative 
treatment  of  the  abscesses,  establishing  perfect  drainage,  but  even  then 
the  seat  of  disease  is  often  inaccessible  and  for  a  long  time  the  abscess 
cavity  may  discharge  from  sinuses. 

DlAUNOSIS. 

The  ordinary  clinical  history  of  a  case  is  of  little  value  as  an  aid 
in  establishing  the  presence  of  the  disease.  It  may  be  significant 
enough  to  create  a  strong  suspicion  of  the  existence  of  vertebral  disease. 


Fig.  37.— Rigidity  of  Spine  in  Pott's  Disease.    (Children's  Hospital  Report.) 

but  without  definite  physical  signs,  a  diagnosis  of  Pott's  disease  cannot 
be  made.  Too  much  importance  must  not  be  allowed  to  the  tendency  of 
the  parents  to  attribute  the  condition  to  traumatism.      It  should  be  men- 


1  P.  K.  Brown:    Occidental  Med.  Times.  1897,   xi.  ;    John  Dane:    Boston  Med. 
and  Suru.  Journ.,  1895. 


30 


ORTHOPEDIC    SURGERY 


tioned  that  the  absence  of  pain  can  in  no  way  be  ^assumed  to  show  the 
absence  of  Pott's  disease. 

The  diagnosis,  then,  must  be  made  wholly  from  the  physical  exami- 
nation, and  the  chief  physical  signs  upon  which  one  must  rely  can  be 
divided  into  .two  classes :  (a)  those  occurring  from  bony  destruction ; 
and  (b)  those  dependent  upon  muscular  spasm. 

(a)  Signs  due  to  Bony  Destruction. — Since  these  are  made  evident  by 
the  presence  of  angular  deformity  of  the  spine,  which  is  the  result  of 
bony  destruction,  they  are  so  conspicuous  that  they  can  scarcely  be  over- 
looked. And  the  prominence  of  one  or  more  of  the  vertebral  bodies, 
associated  with  muscular  spasm,  is  a  positive  sign  of  the  presence  of  the 
disease,  unless  it  is  the  result  of  a  fracture  of  the  spine,  or  in  adults  the 


Fig.  38.— Normal  Flexibility  of  Spine.    (Children's  Hospital  Report.) 


outcome  of  malignant  disease,  aneurism  of  the  aorta,  or  some  similar 
affection.  In  the  larger  number  of  cases,  as  they  come  to  the  surgeon, 
this  bony  deformity  has  occurred,  and  the  diagnosis  can  be  made  at  a 
glance ;  but  the  most  important  class  of  cases,  so  far  as  the  diagnosis  is 
concerned,  are  those  in  which  bony  destruction  has  not  yet  begun,  and 
in  which  the  need  of  an  early  diagnosis  is  evident,  in  the  hope  that  it  may 
lead  to  treatment  which  may  be  sufficient  to  prevent  the  occurrence  of 
deformity. 

(p)   Signs  Arising  from  Muscular  Spasm. — These  are: 

1.  Stiffness  of  the  spine  in  walking  and  in  passive  manipulation. 

2.  Peculiarity  of  gait  and  attitudes  assumed,  according  to  the  loca- 
tion of  the  disease. 

3.  Lateral  deviation  of  the  spine." 

Por  all  examinations  children  should  be  stripped. 

1  Boston  Med.  and  Surg.  Jour.,  October  9th,  1890. 


pott's  disease.  31 

1.  Muscular  Stiffness. — On  examining  for  muscular  stiffness  of  the 
spine,  the  child  is  most  conveniently  laid  face  downward  on  a  table  or 
bed,  and  lifted  by  the  feet.  In  a  normal  back  the  lumbar  and  lower 
dorsal  spine  can  be  markedly  bent,  and  a  general  mobility  of  the  whole 
column  is  seen.  In  patients  in  whom  Pott's  disease  is  present  the  region 
affected  is  held  rigidly  by  muscular  contraction  when  manipulation  is 
attempted.  In  certain  instances  the  erector  spina;  muscles  stand  out  like 
cords  Avhen  the  child  is  lifted,  and  it  is  questionable  how  much  impor- 
tance should  be  attributed  to  this  sign ;  it  occurs  in  cases  of  hip  disease, 
and  in  certain  instances  in  excitable  children  in  whom  no  joint  disease  is 
present.  Lifting  the  patient  by  the  feet  in  this  way  will  show  the  ex- 
istence of  lumbar  or  lower  dorsal  rigidity ;  but  it  does  not  detect  high 


m 

Fig.  39.— Testing  for  Psoas  Contraction.    (Children's  Hospital  Report.) 

dorsal  Pott's  disease.  In  lumbar  Pott's  disease  lateral  mobility  of  the 
spine,  as  well  as  antero-posterior  flexibility,  is  lost. 

2.  Peculiar  Gait  and  Attitudes. — In  considering  the  gait  as  a  di- 
agnostic symptom  of  Pott's  disease,  one  must  be  prepared  to  find  any 
of  the  characteristic  features  absent.  In  general  the  walk  is  careful, 
steady,  and  military,  and  the  steps  are  taken  with  such  care  that  jars  to 
rthe  spine  are  avoided ;  in  other  instances,  however,  the  child  walks  with 
comparative  freedom,  even  when  the  presence  of  the  disease  is  manifest, 
and  the  well-known  test  of  having  the  child  pick  up  objects  from  the 
floor  may  fail  to  detect  anything. 

Assuming,  then,  the  extreme  importance  of  the  early  diagnosis  of  the 
disease  when  practicable,  it  becomes  necessary  to  consider  in  detail  the 
deviations  from  the  normal  signs,  according  to  the  region  of  the  spine 
affected. 

Cervical  Pott's  Disease. — The  most  common  symptom  of  the  disease 
in  this  region,  due  to  muscular  rigidity,  is  the  occurrence  of  wry-neck 


32 


(iK'THOl'KDIC    Nl/RCiEKY. 


with  stiffness  of  the  muscles  of  the  buck  and  neck.  This  is  often  accom- 
panied by  distressed  breathing  at  night,  and  intense  occipital  neuralgia. 
The  head  is  held  sometimes  in  a  very  much  distorted  position,  ;md  the 
most  characteristic  attitude  is  when  the  chin  is  supported  in  the  hand; 
and  when  the.  patient  turns  sideways  to  look  at  objects,  the  whole  body 
is  turned.  In  severe  cases  one  notices  flattening  of  the  back  of  the  neck, 
with  sometimes  bony  deformity.  When  spinal  disease  occurs  in  this 
region  the  early  symptoms  are  most  often  confused  with  sprains,  muscu- 
lar torticollis,  and  inflammation  of  the  cervical  lymphatic  glands. 

From  sprains  the  immediate  diagnosis  is  almost  impossible.     In  the 
early  stages  of  sprains  of  the  neck  the  head  is  often  held  stiffly  and  to 


Pre.  40. — Normal  Flexion  of  spinal  Column. 

one  side;  motion  is  resisted  and  is  painful,  muscular  spasm  is  present, 
and  in  the  case  of  children  of  unintelligent  parents  the  history  cannot  be 
accepted  as  valid. 

From  true  muscular  wry -neck  the  diagnosis  is  often  extremely  diffi- 
cult. In  congenital  torticollis  manipulation  is  generally  not  painful,  and 
one  muscle  is  firmly  contracted  while  the  rest  are  relaxed.  In  Congenital 
cases  the  head  and  face  are  distorted,  and  the  eyes  often  are  not  upon  the 
same  plane.  In  Pott's  disease,  on  the  other  hand,  the  muscular  fixation 
involves  all  the  muscles,  and  movement  in  any  direction  is  resisted,  and 
is  more  apt  to  be  painful.  This  applies  fairly  well  to  cases  of  anterior 
wry-neck;  but  in  cases  in  which  the  true  muscular  torticollis  is  of  the  pos- 
terior variety,  and  is  due  to  a  contraction  of  the  deeper  muscles,  the 
diagnosis  is  much  more  difficult,  for  no  one  muscle  is  contracted,  and 
movement  is  limited  by  a  general  muscular  resistance.  The  writers  have. 
in  mind  cases  in  which  the  diagnosis  has  been  impossible,  and  some  in 
which  an  operation  of  tenotomy  has  been  performed  in  cases  of  Pott's 
disease  in  which  a  most  careful  examination  had  seemed  to  establish  the 
diagnosis  of  true  muscular  wry-neck. 

The  differential  diagnosis  can  be  most  easily  made  by  putting  the 
patient  to  bed  and  seeing  if  the  application  of  extension  is  sufficient 
to  overcome  the  distortion,  as  it  will  do  in  the  course  of  a  few  days  if 


POTT  S   DISEASE.  33 

due  to  Pott's  disease.  Rheumatic  torticollis  .simulates  cervical  Pott's 
disease  so  closely  that  the  physical  signs  are  not  sufficient  at  first  to 
differentiate  the  affections. 

Inflammation  of  the  lymphatic  glands  of  the  neck  may  give  rise  to 
a  position  of  the  head  simulating  wry-neck,  associate!  with  muscular 
spasm. 

Upper  Dorsal  Pott'' s  Disease. — In  this  region  detection  is  the  most 
easy  because  any  bony  destruction  at  once  results  in  angular  deformity, 
on  account  of  the  posterior  curve  of  the  spine  in  this  part,  and  it  is  on 
this  deformity  that  one  must  depend  rather  than  on  symptoms  (hie  to 
muscular  stiffness. 

The  shoulders  are,  however,  held  high  and  squarely,  the  gait  is  mili- 
tary and  careful,  and  lateral  deviation  is  almost  certainly  present.  In 
Pott's  disease,  paralysis  may  exceptionally  be  the  first  perceptible 
symptom. 

The  two  affections  with  which  dorsal  Pott's  disease  is  most  likely  to 
be  confused  are  scoliosis  and  round  shoulders.  From  rotary  lateral 
curvature  with  rigidity  the  distinction  may  be  difficult  in  cases  in  which 
the  kyphosis  is  rounded  and  involves  several  vertebra?.  The  fact  that 
lateral  deviation  of  the  spine  is  so  constantly  associated  with  Pott's  dis- 
ease is  another  factor  in  making  the  distinction  more  difficult. 

Prom  round  shoulders,  Pott's  disease  is  generally  to  be  distinguished 
by  the  fact  that  in  the  former  the  spine  is  flexible  and  the  deformity 
rounded  and  not  angular.     The  distinction  is  generally  easily  made. 

Lumbar  Pott's  Disease. — Vertebral  disease  in  this  region  of  the  spine 
is  difficult  of  detection  on  account  of  the  anterior  curve  of  the  spine  in  the 
lumbar  region,  so  that  in  any  moderate  amount  of  destruction  of  the 
lumbar  vertebral  bodies  no  posterior  angular  curvature  is  developed,  and 
it  is  only  in  the  later  stages  of  the  disease  that  any  angularity  becomes 
prominent.  The  occurrence  of  deformity  is  preceded  by  a  flattening  of 
the  lumbar  curve.  The  attitude  is  that  of  lordosis,  which  in  some  cases 
becomes  very  marked ;  the  gait  is  military  and  careful,  and  lateral  devi- 
ation is  generally  present,  sometimes  to  a  very  marked  degree.  It  is  in 
this  region  of  the  spine  that  it  is  most  conspicuous. 

In  many  instances  of  lumbar  Pott's  disease  the  first  noticeable  symp- 
tom is  a  limp  which  is  due  to  unilateral  psoas  contraction,  the  result  per- 
haps of  abscess  or  perhaps  only  of  psoas  irritability.  Psoas  contraction 
must  be  set  down  as  one  of  the  common  symptoms  of  lumbar  Pott's  dis- 
ease. If  the  child  is  laid  on  its  face  and  an  attempt  is  made  to  flex  the 
lumbar  spine,  it  is  found  to  be  entirely  rigid.  Any  attempt  to  hyperex- 
tend  the  leg  in  this  position  leads  to  the  detection  of  the  slightest  psoas 
irritability. 

Lumbar  Pott's  disease  is  most  liable  to  be  confused  with  single  or 
double  hip  disease,  and  with  rhachitic  curvature  of  the  spine. 
3 


o-L  ORTHOPEDIC    SURGERY, 

The  differential  diagnosis  between  lumbar  Pott's  disease  and  hip  dis- 
ease is  one  at  times  difficult,  although  it  is  not  generally  considered  so. 
"When  the  hip  symptoms  are  due  to  Pott's  disease  and  are  caused  by 
psoas  irritability,  the  restriction  of  motion  in  the  hip  is  simply  in  the 
loss  of  hyperextension,  while  abduction  and  internal  rotation  are  free 
and  not  affected.  This  limitation  of  motion  in  only  one  direction  is 
generally  sufficient,  in  connection  with  the  other  symptoms,  to  establish 
the  presence  of  Pott's  disease.  On  the  other  hand,  in  some  cases  the 
limitation  of  the  hip's  motion  is  in  all  directions,  and  simulates  very 
closely  the  limitation  of  true  hip  disease. 

Another  element  which  leads  to  the  confusion  of  the  two  affections  is 
the  rigidity  of  the  lumbar  spine  which  often  occurs  as  an  accompaniment 
of  acute  hip  disease.  If  a  child  with  hip  disease  is  laid  upon  its  face, 
and  an  attempt  made  to  flex  the  lumbar  spine  by  lifting  the  feet  from  the 
table,  the  irritability  of  all  the  muscles  is  so  great  that  often  the  lumbar 
spine  will  appear  to  be  completely  rigid,  and  only  a  very  careful  exami- 
nation will  show  that  this  is  secondary  to  the  hip  disease. 

Ehachitic  deformity  of  the  spine  is  a  posterior  curvature  often  so 
sharp  as  to  be  angular.  It  occurs  at  the  junction  of  the  dorsal  and  the 
lumbar  regions.  This  junction  is  also  a  frequent  site  of  Pott's  disease. 
Muscular  stiffness  may  not  be  present. 

Rhachitic  curvature  of  the  spine  is  characterized  by  persistent  stiff- 
ness in  most  cases,  so  that  if  the  child  is  laid  upon  its  face,  and  an 
attempt  is  made  to  flex  the  spine,  the  curve  is  not  obliterated.  The 
symptoms,  therefore,  are  the  same  that  would  be  presented  by  Pott's 
disease  occurring  under  the  same  conditions,  and  much  dependence  must 
be  placed  upon  the  coexistence  of  rickets.  It  is  often  of  use  to  treat 
such  cases  by  rest  on  a  frame,  and  if  the  curve  is  rhachitic,  mobility  will 
be  restored  to  the  back  within  the  course  of  a  few  months. 

The  Diagnosis  of  Abscess.- — The  diagnosis  of  abscess  in  Pott's  disease 
rarely  presents  any  difficulty,  but  in  certain  instances  their  occurrence  is 
attended  with  peculiar  symptoms  which  may  give  rise  to  some  obscurity. 
In  the  cervical  region  the  most  common  seat  of  abscess  formation  is  in 
the  back  wall  of  the  pharynx,  where  it  often  persists  for  some  time  un- 
recognized, giving  rise  to  a  peculiar  series  of  respiratory  symptoms.  The 
pharyngeal  wall  is  pushed  forward,  and  the  child  breathes  at  night  with 
a  peculiar  snoring  respiration,  which  is  to  a  certain  extent  characteristic. 
There  is  some  difficulty  in  swallowing  food;  the  pain  is  apt  to  be  severe; 
and  occasionally  a  swelling  extends  so  much  to  the  side  as  to  be  notice- 
able at  the  side  of  the  neck.  The  finger  introduced  into  the  mouth  comes 
upon  a  projecting  swelling  of  the  back  of  the  pharynx,  which  is  charac- 
teristic and  not  to  be  mistaken. 

In  the  dorsal  and  lumbar  region  the  abscesses  point  for  the  most  part 
in  the  loin,  or  follow  down  the  course  of  the  psoas  muscle  to  appear  in 


POTT'S   DISEASE.  35 

the  upper  part  of  the  thigh  or  groin.  Appearing  in  the  back  the  abscess 
is  not  likely  to  be  mistaken  for  anything  unless  for  an  abscess  of  the  bark 
muscles  or  a  lipoma. 

Appearing  in  the  groin  the  abscess  may  be  mistaken  for  hernia  which 
it  sometimes  resembles  rather  closely,  and  gives  a  certain  obscure  im- 
pulse on  coughing ;  but  it  is  irreducible  and  the  part  of  the  psoas  muscle 
within  the  abdomen  can  be  felt  to  be  enlarged  and  resistant.  Psoas  con- 
traction is  present,  which  causes  flexion  of  the  leg. 

The  Diagnosis  of  Paralysis. — Paralysis  in  Pott's -disease,  although 
ordinarily  one  of  the  later  symptoms,  may  occasionally  precede  the  de- 
formity, and  be  the  first  sign  of  the  presence  of  vertebral  disease.  Such 
cases  are  not  so  rare  that  they  should  be  overlooked.  The  occurrence  of 
myelitis  in  a  young  child  should  be  considered  as  extremely  suspicious, 
and  as  being  more  likely  to  be  due  to  Pott's  disease  than  to  any  other 
cause,  even  if  the  signs  of  vertebral  disease  are  obscure  or  apparently 
absent.  In  general  the  paralysis  is  preceded  by  a  stage  of  the  dis- 
ease in  which  pain  is  much  increased.  Ordinarily  one  of  the  first 
demonstrable  signs  is  an  increase  of  the  patella  reflexes,  with  perhaps 
ankle  clonus. 

Sprain. — It  is  difficult  at  times  to  differentiate  a  sprain  of  the  vertebral 
column  from  Pott's  disease.  After  a  fall  in  which  the  back  has  been 
wrenched,  a  child  begins  to  walk  stiffly  and  to  complain  of  pain  in  the 
back  and  perhaps  in  the  legs.  Attitudes  characteristic  of  Pott's  disease 
are  assumed,  the  trunk  is  supported  with  the  hands  upon  the  thighs,  the 
back  is  kept  stiff  in  stooping,  and  passive  manipulation  shows  that  mus- 
cular rigidity  is  present.  At  an  early  stage  a  diagnosis  is  sometimes 
clearly  impossible.  But  in  sprains  of  the  back  the  tendency  is  to  a  rapid 
recovery  under  proper  conditions,  and  the  result  establishes  the  diagnosis. 
Severe  sprains  of  the  back  are  comparatively  rare  in  childhood,  but  in 
adult  males  engaged  in  laborious  occupation  cases  of  strain  are  more 
common  than  cases  of  Pott's  disease.  The  diagnosis  is  one  which  should 
be  made  in  childhood  with  very  great  reserve. 

Rotary  lateral  curvature  of  the  spine  is  an  entirely  different  affection 
from  Pott's  disease.  It  is  not  the  result  of  a  tuberculous  destruction  of 
bone,  but  is  the  result  of  a  distorted  and  abnormal  process  of  growth.  It 
is  characterized  not  by  an  angular  projection  of  the  spine  backward,  but 
by  a  gradual  curve  of  the  spine  laterally  with  a  rotation  of  the  vertebral 
column  on  its  long  axis.  Pain  is  not  present,  and  the  recognition  of  the 
affection  is  generally  due  to  an  alteration  in  the  outlines  of  the  trunk, 
and  a  prominence  of  the  shoulder  or  hip. 

In  most  cases  the  diagnosis  is  not  at  all  obscure.  But  in  the  course 
of  Pott's  disease  at  an  early  stage  a  lateral  deviation  may  be  present, 
which  may  be  mistaken  for  lateral  curvature.  On  a  careful  examination 
it  will,  however,  be  found  that  a  stiffness  of  the  back  is  present  which 


3t)  ORTHOPEDIC    SURGERY. 

is  never  to  be  seen  at  an  early  stage  of  lateral  curvature.  In  some  in- 
stances careful  and  repeated  examinations  are  needed  to  establish  a  posi- 
tive opinion. 

A  lateral  deviation  takes  place  also  sometimes  in  old  cases  of  caries  of 
the  spine  in  connection  with  an  old  kyphotic  curve. 

Hypercesthetic  spine,  also  termed  the  hysterical  spine,  and  the  neuronii- 
metic  spine,  is  characterized  by  tenderness  in  certain  portions  of  the  back, 
sometimes  accompanied  by  pain  or  ache.  This  condition  is  more  common 
in  neurotic  persons,  but  may  be  seen  in  others  who  have  been  suffering 
from  nervous  exhaustion  from  any  cause.  It  generally  follows  some 
slight  or  severe  accident  and  generally  occurs  in  persons  with  weak  back 
muscles.  The  tenderness  may  be  intense  and  manifestly  exaggerated,  or 
it  may  be  only  slight,  and  confined  to  small  spots  in  the  lower  cervical 
and  upper  dorsal  or  in  the  upper  lumbar  region.  As  a  rule,  no  real  stiff- 
ness in  the  back  is  present,  but  in  severe  cases,  or  in  cases  which  have 
remained  in  bed  for  some  time,  muscular  stiffness  may  be  present.  This 
condition  is  sometimes  seen  after  railway  accidents.  In  the  cases  that 
are  termed  "railway  spine,"  abnormal  projection  or  deformity  in  the 
spine  does  not  exist,  although  lax  ligaments  and  weak  muscles  permit  a 
flexed  condition  of  the  spinal  column  in  standing,  which  may  make  one 
or  two  vertebras  unduly  prominent  as  the  patient  stands  erect,  but  this 
prominence  disappears  in  recumbency.  Referred  pains,  or  the  attitude 
and  gait  characteristic  of  Pott's  disease,  are  absent.  A  hyperaesthetic 
spine  occurs  in  advdts,  and  especially  in  growing  young  girls;  it  may 
exceptionally  be  seen  in  children. 

Malignant  disease  of  the  spine  presents,  when  a  projection  is  found,  a 
more  rounded  and  less  sharp  projection  than  is  seen  in  the  beginning  of 
caries.  Carcinoma  of  the  spine  is  usually  secondary.  The  symptoms, 
however — pseudo-neuralgias,  paresis  and  paralysis,  muscular  stiffness — 
are  the  same  in  both,  and  sometimes  only  a  conjectural  diagnosis  can  be 
made.      Sarcoma  of  the  spine  is  very  rare  in  childhood. 

Much  the  same  may  be  said  of  the  curvatures  of  the  spine  caused  by 
aneurism,  except  that  the  diagnosis  is  usually  made  by  auscultation  or 
by  the  rational  symptoms  before  the  spine  is  noticeably  affected. 

Tumors  pressing  on  the  spinal  cord  may  cause  stiffness  of  the  back 
and  pain  referred  to  the  peripheral  ends  of  the  nerves.  Angular  deformity, 
however,  is  absent,  and  the  symptoms  of  nervous  disturbance  predomi- 
nate over  the  ordinary  ones  of  Pott's  disease. 

Traumatic  S^>ondylitis. — A  condition  in  the  spine  is  said  to  exist,  after 
severe  traumatism,  which  simulates  Pott's  disease.  The  distinction 
between  a  n  on -infectious  destructive  inflammation  of  the  vertebras  and  a 
tuberculous  inflammation  cannot  be  made  ante  mortem  in  most  cases,  ex- 
cept possibly  by  the  injection  of  tuberculin.  The  same  may  be  said  of 
actinomycosis  of  the  spine. 


pott's  disease.  37 

Syphilis  of  the  spine  must  be  diagnosticated  by  general  symptoms 
rather  than  by  any  well-known  characteristics  that  it  possesses. 

Osteomyelitis  of  the  spine  affects  most  often  children;  it  may  be 
secondary  or  primary.  The  back  part  of  the  vertebral  column  is  often 
affected,  and  tenderness  is  present  at  the  seat  of  disease.  Suppuration 
elsewhere  occurs  in  sixty  per  cent  of  all  cases.  There  is  much  constitu- 
tional disturbance,  fever  is  high,  and  the  course  rapid.  (Edema  of  the 
affected  parts  appears  early;  abscesses  of  a  very  acute  and  extensive 
character  as  well  as  paralysis  are  other  early  features.  The  formation  of 
a  kyphus  of  any  extent  is  unusual. ' 

Acute  abdominal  affections  may  simulate  severe  Pott's  disease.  In  a 
case  seen  by  the  writers  fixation  of  the  spine  was  a  most  evident  feature. 

Spondylolisthesis  may  resemble  Pott's  disease.  The  same  may  be 
said  of  typhoid  spine.      These  will  be  described  later. 

Rheumatoid  arthritis  (spondylitis  deformans  of  the  spine)  is  an  affec- 
tion most  frequent  in  adult  life,  characterized  by  stiffness  and  some 
arching  of  the  spine ;  there  is  usually  little  muscular  spasm  and  no  un- 
usual projection  of  the  spinous  processes;  in  some  instances  the  ribs  are 
ankylosed  to  the  spine,  so  that  no  expansion  of  the  chest  is  possible. 
Stiffness  of  the  back  is  present,  but  the  whole  spine  is  rigid  and  other 
joints  are  involved.  Many  of  these  cases  occur  in  connection  with  gon- 
orrhoea. Patients  suffering  from  this  affection  may  have  neuralgic  or 
pseudo-neuralgic  pains  of  the  nerves  issuing  from  the  spine  at  the  affected 
part. 

With  regard  to  the  symptoms  of  sacro-iliac  disease,  perinephritis,  and 
appendicitis,  it  may  be  said  that  a  mistake  in  diagnosis  may  happen,  but 
that  ordinarily  there  is  no  obscurity.  It  should,  however,  be  borne  in 
mind  that  in  appendicitis  and  in  perinephritis,  when  an  abscess  is  pres- 
ent, a  contraction  of  the  thigh  may  occur,  resembling  that  seen  in  psoas 
abscess.  The  absence  of  a  projection  or  irregularity  of  the  back,  and  the 
power  of  muscular  movement  of  the  back  in  these  cases,  will  help  to 
establish  the  fact  that  they  are  not  due  to  disease  of  the  spine. 

Prognosis. 

Pott's  disease  will  always  be  regarded  as  one  of  the  most  formidable 
of  diseases ;  its  long  course,  the  deformity  entailed,  the  severity  of  the 
complications,  and  the  occasional  termination  in  death  give  both  to  the 
surgeon  and  to  the  non-professional  public  a  natural  dread  of  the  affec- 
tion. These  inferences  are,  however,  drawn  from  the  severer  cases,  and 
facts  show  that  the  disease  has  a  tendency  to  spontaneous  recovery,  that 
in  certain  parts  of  the  spine  deformity  can  be  prevented,  and  that  in  few 

'Ann.  of  Surg.,  1896,  xxiii.,  510;  Halm :  Beitr.  f.  klin.  Chir.,  xiv.,  Hft.  1; 
Mfiller:    Deutsch.  Zeit.  f.  Chir..  xli. 


38 


ORTHOPEDIC   SURGERY. 


affections  does  the  work  of  the  surgeon  give  greater  relief  than  in  Pott's 
disease. 

Mortality. — No  statistics  of  value  exist  as  to  the  percentage  of  mor- 
tality and  recovery.  Billroth  and  Menzel  report  2'.)  deaths  in  61  cases ; 
Jaffe  22  deaths  in  82  cases,  and  Mohr  7  deaths  in  72  cases.  In  a  dis- 
ease having  so  long  a  course,  a  number  of  patients  should  be  watched  for 
a  long  number  of  years  in  order  to  obtain  statistics  of  value.  The  per- 
centage of  mortality  would  be  greater  in  adults  than  in  children.  In  a 
certain  number  of  cases  spontaneous  recovery  has  taken  place  in  oarly 
childhood.  Many  specimens  in  museums  also  exist,  which  show  bony 
union  with  entire  cessation  of  the  pathological  process. 

Billroth  and  Menzel  found,  in  autopsies  of  702  cases,  tuberculosis  of 
other  parts  of  the  body  in  more  than  one-half   (5(5  per  cent).     Amyloid 


FEB.  6.1881 


AUG.29.1883 
MAR  30  1877 
FE  BY  301871 


C      D      E 

FiG.  41.— Tracings  of  the  Deformity  in  Pott's  Disease.    A  B,  not  treated  ;CDB,  patient  did  not  con- 
tinue treatment ;  F  G  H,  patient  discontinued  treatment.    (H.  L.  Taylor.) 


degeneration  was  found  in  15  per  cent  of  the  cases,  and  fatty  degenera- 
tion of  the  kidney  in  22  per  cent.  Mohr,  however,  found  the  latter  in 
only  6  per  cent  of  the  cases  collected  by  him.  Mohr  found  tuberculosis 
of  the  lungs  in  only  8  out  of  61  autopsies. 

Michel  gives  as  causes  of  death  in  44  cases  of  spinal  abscess :  in  14, 
tuberculosis  of  lungs ;  in  16,  marasmus ;  in  5,  sloughing  of  limbs  from 
oedema;  in  4,  pyaemia;  in  2,  arachnitis;  in  2,  pus  in  the  medullary 
canal ;  and  in  1,  pneumonia. 

Neidert  investigated  the  cause  of  death  in  patients  with  angular  de- 
formities of  the  spine,  the  result  of  Pott's  disease,  which  had  been  cured. 
Patients  with  severe  deformities  ordinarily  die  of  heart  fatigue,  patients 
with  medium-sized  curvatures  die  oftenest  of   phthisis  and  die  young, 


pott's  disease. 


while  those  with  small  deformities  have  nearly  as  good  a  prospect  of  Long 
life  as  men  with  normal  spines.  These  results  Avere  obtained  from  the 
investigation  of  .'>1  specimens  in  the  Munich  Pathological  Institute. 
Twenty-four  had  hypertrophy,  with  or  without 
dilatation  of  the  right  side  of  the  heart,  4  had 
muscular  degeneration  of  the  heart  walls,  and  2 
had  stenosis  of  the  mitral  valve,  1  showed  acute 
miliary  tuberculosis,  8  died  of  phthisis,  4  of 
pneumonia,  and  1  of  carbuncle.1 

Mohr,  in  9  cases  of  fatal  abscess,  found  per- 
foration into  the  oesophagus  in  2;  pleura  and 
lungs  in  2;  pleura  alone  in  1;  peritoneum  in  1; 
spinal  canal  in  2.  Death  has  occurred  from  the 
rupture  of  a  spinal  abscess,  which  has  discharged 
into  the  bronchi. 

Abscesses  in  adults  must  be  looked  upon  as 
much  more  unfavorable  as  to  prognosis  than  in 
children.  The  prognosis  will  depend  largely 
upon  the  situation  of  the  abscess,  the  complete- 
ness of  evacuation,  and  the  amount  of  drainage 
possible. 

The  occurrence  of  psoas  abscess  -and  contrac- 
tion of  the  thighs  will  add  much  to  the  difficulty 
and  the  length  of  treatment.  Abscess  in  itself 
does  not  make  the  prognosis  much  more  grave, 
although,  as  a  rule,  abscesses  characterize  severer 
grades  of  cases.     The  discharge  is    likely  to  be 

prolonged  and  exhausting,  and  the  sinuses  are  likely  to  continue  open 
for  a  long  time,  perhaps  for  months  and  years. 

Age. — The  prognosis  in  the  case  of  adults  is  not  nearly  so  favorable 


Fig.  42.— Result  in  a  Severe  Case 
of  Dorsal  Pott's  Disease. 


Fig.  43.— Case  of  Neglected  Pott's  Disease  with  Psoas  Contraction  and  Severe  Deformity. 

as  in  the  case  of  children,  and  it  should  be  very  guarded  both  as  to  ulti- 
mate recovery  and  the  permanent  benefit  to  be  derived  from  treatment. 


1  "Causes  of  Death  in  Deformities  of  Vertebral  Column,"  Inaug.  Diss.,  Munich, 


1886. 


40 


ORTHOPKDK'    SURGERY. 


Phthisis  is  more  likely  to  develop  than  in  children,  and  the  local  proc- 
ess seems  to  possess  an  activity  greater  than  in  young  children. 

Deformity.  — Ihe  tendency  of  the  deformity  is  to  increase,  and  this  is 
specially  marked  in  the  upper  dorsal  region.  Instances  of  arrest  without 
marked  deformity  are  not  so  very  rare  in  upper  cervical  disease  and  in 
lumbar  disease,  but  in  the  upper  and  middle  dorsal  regions  the  tendency 
is  for  an  increase  of  the  deformity  proportionate  to  the  extent  of  the 


3 

£L_) 

i      fig- 

r*M 

^R      n^M 

»■ 

\                    1 

Jr 

See— —"-^ 

Fir,.  U—  Child  with  Pott's  "Disease  Pick- 
ing up  Object  from  Floor. 


Fig.  45.— Normal  Child  Picking  up  Object  from  Floor. 


disease.  In  most  cases,  some  arrest  of  the  growth  of  the  whole  child 
takes  place  apart  from  the  loss  of  vertebral  substance.  The  cure  from 
Pott's  disease  may  be  so  complete  as  to  permit  normal  labor,  provided  no 
distortion  of  the  pelvis  has  taken  place. ' 

Treatment. 

This  varies  according  to  the  stage  and  condition  of  the  pathological 
process. 

When  the  destructive  ostitis  is  acute  and  extensive  the  affected  bone 
should  be  protected  from  all  jar  and  pressure,  both  that  due  to  super- 
imposed weight  and  attitude.  When  cicatrization  has  begun  the  spine 
should  be  protected  so  that  activity  necessary  for  health  may  not  cause 
injury  in  the  imperfectly  healed  bone  structure. 


'Trans.  Anier.  Ort.li.  Assn.,  vol.  iv. 


POTT  S    DISK  ASK 


+  1 


Protection  is  necessary  until  the  previously  inflamed  bone  has  become 
cicatrized  so  thoroughly  as  to  withstand  without  injury  jar  and  superim- 
posed pressure. 

A  growing  spinal  column,  even  if  the  vertebra-  have  recovered  from 
caries,  may  need  support  to  prevent  an  increase  of  curvature  by  abnormal 
growth. 

Treatment  therefore  is  different  in  the  acute,  the  subacute,  and  the 
convalescent  stages.      In  the  acute  stage  recumbency  is  the  most  efficient 


FIG.  4B-— -Tracings  from  Cases  of    Pott's  Disease  Showing  the  Recession  of  the  Deformity   under    Me- 
chanical Treatment. 

method.     In  the  subacute  and  convalescent  stage  ambulatory  treatment 
with  more  or  less  efficient  spinal  protection  is  advisable. 


Treatment  by  Recumbency. 


If  the  patient  lies  upon  his  back,  or  upon  his  face,  on  a  hard  surface, 
there  is  no  superincumbent  weight  pressing  upon  any  portion  of  the  spine. 
If  the  patient  lies  upon  his  back  upon  a  spring-bed,  and  the  bed  sags,  the 
spine  is  of  course  bent,  and  pressure  upon  the  vertebrae,  proportional  in 
amount  to  the  extent  of  the  curve,  results. 

If  treatment  by  recumbency  is  to  be  adopted,  it  is  not  sufficient  sim- 
ply to  place  the  child  in  bed.  Sagging  of  the  mattress,  moving  of  the 
patient  from  side  to  side,  twisting  and  turning  are  all  injurious,  in  that 
they  cause  motion  between  the  vertebree  and  change  interarticular  press- 
ure, both  of  which  are  undesirable. 

It  is  necessary  that  the  child  should  be  fixed  in  a  suitable  position  in 
bed.  This  can  be  done  by  securing  the  child  in  such  a  manner  that  the 
vertebral  column  at  the  seat  of  disease  is  arched  forward,  diminishing  the 


42  ORTHOPEDIC    SURGERY. 

interarticular  pressure.      The  simplest  way  of  doing  this  is  by  means  of 
a  frame. 

The  rectangular  bed  frame  consists  of  a  stretcher  of  heavy  cloth  at- 
tached to  a  rectangular  gas-pipe  frame.  This  frame  is  made  of  straight 
pieces  of    galvanized  iron  gas-pipe  (one-half  to  one  inch  in  diameter) 


Fig.  47.— Gas-Pipe  Frame.    (Children's  Hospital  Report.) 

screwed  into  gasfitter's  joints  at  the  four  corners.  This  frame  should 
be  four  or  five  inches  longer  than  the  patient,  and  its  width  should  be  a 
little  less  than  the  extreme  width  of  the  shoulders. 

The  covering  cloth  is  best  made  of  heavy  unbleached  cotton  sheeting, 
stretched  firmly  over  the  stretcher.  The  covering  should  consist  of  two 
pieces  of  such  length  that  the  entire  space  is  covered  by  cloth,  except  for 
a  space  of  six  inches  or  less  between  the  two  sections  at  a  point  corre- 
sponding to  the  buttocks.  The  cloth  covering  can  be  stretched  tightly, 
and  this  may  be  done  in  one  of  several  ways.     The  most  convenient  way 


Fig.  48.— oas-Pipe  Selva  Frame  Covered.    (Children's  Hospital  Report.) 

is  by  lacing  each  section  at  the  back  of  the  frame.  Hemmed  lacing  holes 
are  made  in  the  doubled  edge  of  the  cloth,  about  an  inch  apart,  and  a 
stout  lacing  is  passed  from  one  to  the  other.  Buckles  and  webbing 
straps  may  be  used  in  place  of  the  lacing,  but  the  buckles  are  likely  to 
press  upon  the  patient's  back,  and  the  lacing  is  preferable. 

The  child  lying  upon  this  frame  can  be  secured  by  means  of  straps 
across  the  shoulders  and  pelvis  and  knees,  and  can  be  carried  about  with- 


pott's  disease.  43 

out  jar.     When  the  frame  is  placed  upon  the  bed,  the  cloth  covering  is 
no  more  uncomfortable  than  the  surface  of  the  bed. 

But  simple  recumbency  is  not  sufficient  to  favor  cicatricial  ostitis. 
The  removal  of  intervertebral  pressure  is  desired.  This  is  to  be  accom- 
plished by  arching  the  spinal  column  forward  at  the  point  of  the  kyphotic 
curve.  When  the  cicatrization  has  not  progressed  so  far  as  to  produce 
ankylosis,  correction  (partial  or  complete)  of  the  curve  can  lie  effected 
by  placing  under  the  curve  of  the  child  lying  upon  the  back  a  firm  pad, 
pressing  upon  each  side  of  the  spinous  process,  and  sufficiently  high  to 
press  this  part  upward  while  the  rest  of  the  spinal  column  drops  back  \>y 


Fig.  49.— Traction  in  Cervical  Caries.    (Children's  Hospital  Report.) 

its  own  weight.  The  pads  can  be  furnished  by  properly  folded  sheets 
or  towels,  by  felt  padding,  or  by  a  plaster-of-Paris  back  moulded  to  a 
corrected  position  of  the  spine. ' 

A  child  undergoing  treatment  on  the  frame  should  be  turned  once  a 
day  to  have  the  back  washed,  rubbed  with  alcohol,  and  powdered.  It  is 
important  that  there  should  be  no  pads  in  the  median  line  immediately 
above  or  below  the  deformity,  but  that  the  pads  should  lie  entirely  out- 
side of  the  line  of  the  spinous  processes.  To  secure  better  fixation  it 
may  at  times  be  necessary  to  place  pads  under  the  lumbar  region. 

In  cervical  caries  head  traction  in  a  recumbent  position  will  be  found 
of  use  in  cases  of  torticollis ;  and  in  severe  neuralgia  from  cervical  caries 


1  The  need  of  support  under  the  recumbent  spinal  column  is  made  clear  by  some 
interesting  observations  made  by  Dr.  H.  J.  Hall,  of  Marblehead,  on  the  spinal  column 
with  the  patient  lying  upon  a  transparent  glass  plate.  This  showed  conclusively 
that  even  on  a  firm  surface  support  is  needed  under  a  portion  of  the  spine  (vide 
Trans.  Am.  Orthopedic  Association,  vol.  ix.). 


-14-  ORTHOPEDIC    SURGERY. 

the  relief  afforded  is  often  very  marked.  Traction  can  be  furnished  by 
means  of  a  head  sling  passing  over  the  forehead  and  occiput,  which  is 
attached  to  a  weight  and  pulley  running  over  the  head  of  the  bed  or  to 
the  head  of  the  frame.  The  counter  pull  may  be  furnished  by  the  weight 
of  the  body  in  case  the  head  of  the  bed  is  raised,  by  a  downward  pull 
upon  the  trunk  through  a  waist  band,  or  by  means  of  traction  applied  to 
the  limbs. 

Treatment  by  recumbency  will  be  found  of  service,  either  alone  or  in 
conjunction  with  other  methods,  in  cases  with  acute  symptoms,  in  cases 
of  severe  cervical  caries,  in  cases  with  marked  lateral  deviation  of  the 
spine,  in  paralysis,  in  cases  of  psoas  contraction  and  abscess,  in  cases 
which  do  not  progress  well  under  ambulatory  treatment,  and  which  lose 
flesh  and  strength,  and  in  very  small  children  in  whom  the  difficulty  of 
fixing  the  spine  by  apparatus  is  great. 

Patients  who  have  been  suffering  will  often  be  found  to  gain  flesh 
after  the  relief  afforded  by  recumbency,  though  the  muscles  in  the  limbs 
diminish  in  size. 

Treatment  by  recumbency,  if  used,  should  be  thorough.  Half  meas- 
ures have  the  evils  of  the  imprisonment  without  the  benefit  of  fixation. 
The  limit  of  its  usefulness  is  usually  marked  by  the  restlessness  of  the 
patient.  In  children  the  irksomeness  of  the  confinement  is  borne  readily ; 
but  in  adults  the  imprisonment  constitutes  a  serious  obstacle  to  the  em- 
ployment of  the  method. 

The  objections  to  treatment  by  recumbency  are  evident.  Pott's  dis- 
ease is  a  tuberculous  affection  and  close  confinement  is  injurious  to  pa- 
tients with  a  tuberculous  taint.  Patients  of  this  sort  need  all  possible 
help  from  fresh  air  and  exercise,  and  the  method  of  treatment  by  recum- 
bency for  years,  formerly  the  only  thorough  method  possible,  is  not  now 
regarded  as  necessary  in  all  cases.1 

In  cases  causing  much  anxiety,  recumbency  should  for  a  while  form 
an  essential  part  of  the  treatment.  If  recumbency  is  continued  for  too 
long  a  period,  the  patient's  condition  ceases  to  improve  and  the  tonic  of 
improved  circulation  and  activity  is  required.  After  some  experience  a 
surgeon  will  learn  to  estimate  for  what  cases  recumbency  is  most  advis- 
able. It  may  be  stated  that  such  patients  as  become  easily  tired  when 
on  their  feet  and  those  who,  though  well  supported  mechanically,  fre- 
quently desire  to  lie  down,  will  improve  if  all  weight  can  be  taken  from 
the  spinal  column. 

When  the  time  for  recumbency  is  judged  to  be  ended  it  should  not  be 


1  It  must  be  remembered  that  all  apparatus  is  necessarily  imperfect  from  a  me- 
chanical point  of  view  and  must  fail  in  wholly  relieving  the  diseased  vertebrae  of 
their  weiglnVbearing  function,  so  that  within  its  limitations  recumbency  is  to  be 
recognized  as  mechanically  the  most  efficient  mode  of  treatment  and  the  least  likely 
to  encourage  deformity. 


POTT  S   DISEASE.  to 

discontinued  suddenly,  but  the  patient  should  be  gradually  allowed  to  sit 
up  and  walk  with  proper  mechanical  support.  In  cases  convalescent 
from  paralysis  and  ill  cases  in  which  the  general  prostration  is  extreme, 
exercise  may  be  obtained  by  the  use  of  one  of  the  wheel  crutches,  such 
as  Darrach's.  In  convalescent  cases  ambulatory  treatment  with  hours  of 
rest  in  the  recumbent  position  each  day  should  constitute  the  treatment. 

Rectification  of  the  Deformity  (Forcible  Correction) . — The  treatment 
of  Pott's  disease  by  forcible  correction  may  be  considered  as  an  ad- 
junct to  the  methods  of  treatment  mentioned.  Forcible  correction  of 
the  deformity,  with  or  without  amesthesia,  is  a  method  revived  in  re- 
cent times  by  Chipault  of  Paris,  although  ordinarily  identified  with 
the  name  of  Calot  of  JJerck-sur-Mer.     Chipault  operated  first  in  Sep- 


Fig.  5(1.— Reduction  by  the  Method  of  Calot.    (Redard.) 

tember,  1893,  reducing  the  deformity,  wiring  together  the  spinous 
processes  of  the  affected  vertebrse.  He  published  an  account  of  this 
method  on  March  9th,  1895. l  Calot  published  a  paper  on  the  method  on 
December  22d,  1896,  in  which  he  said  that  his  first  operations  "  dated 
back  only  a  little  over  a  year."  The  priority  of  forcible  reduction  be- 
longs clearly  to  Chipault.  Wiring  of  the  spinous  processes  of  the  verte- 
brae was,  however,  first  advocated  by  an  American,  B.  E.  Hadra,  in  a 
paper  read  and  discussed  before  the  American  Orthopedic  Association  at 
Washington,  September  24th,  1891.  The  method  has  been  largely 
advocated  and  finds  a  place  in  modern  orthopedic  treatment."  It  has 
been  demonstrated  that  under  ether  a  recent  deformity,  even  of  large 
size,  may  be  partially  or  wholly  corrected.     Also  that  much  temporary 


1  Medecine  Moderne,  No.  20,  sixieme  ann^e. 

*Monod:  Gaz.  des  Hop.,  1897,  70,   656;  Menard:  Gaz.  MeU  de  Paris,  1897,   10. 
S.  i.,  231. 


46  ORTHOPEDIC   SURGERY. 

improvement  in  the  deformity  may  be  effected  by  exerting  traction  or 
moderate  pressure  on  the  deformity  without  the  use  of  an  anaesthetic.  It 
has  been  shown  that  this  is  not  a  proceeding  attended  with  as  great  risk 
to  life, '  either  near  or  remote,  as  would  have  been  supposed.  Many  casu- 
alties, however,  of  various  sorts  have  been  reported.2  It  has  been  shown 
that  paralysis  is  often  improved  or  cured  by  this  manipulation,  although 
cases  of  paralysis  occurring  after  it  have  been  reported.3 

Hemorrhage,  rupture  of  the  pleura, 4  rupture  of  abscesses, 5  and  frac- 
ture of  the  spine6  are  among  the  results  reported,  following  injudicious 
application  of  the  method. 

In  610  cases7  recorded  by  twenty -nine  various  operators,  the  results 
reported  have  been  as  follows : 

Length  of  time  elapsed  : 

Varies  from  2  clays  to  2£  years. 
In  separately  detailed  cases  : 

7  were  more  than  1  year       after  correction. 
85     "        "        "     G  months      "  " 

S5     •'        "        "      3 
20     ■■      less      "      3        "  "  " 

Deaths  reported : 

From  all  causes 21 

Meningitis 5 

General  tuberculosis 4 

Trauma  of  the  operation 4 

Intercurrent  disease 3 

Unstated 5 

Autopsies : 

All  showed  a  considerable  local  trauma.     No  case  showed  effectual  effort 
at  repair.      (One  being  two  and  one-half  years  subsequent  to  correction.) 
Immediate  dangers : 

Respiratory  embarrassment 7  cases. 

Pain 6      " 

Shock  (severe) 2      " 

Indirect  effect : 
Abscess. 

Reported  present  before  the  operation 18  cases. 

Ruptured 4  cases. 

Benefited  or  absorbed 5      " 

Appeared  subsequently   2      " 


1  Calot,  e.g.,  204  cases,  2  deaths  inside  of  eight  months. 

2  Jonnesco:  Communication  to  Twelfth  International  Congress  of  Medicine. 
3Lorenz:  Deutsch.  med.  Wochen.,  1897,  556. 

4Wullstein:  Arch.  f.  klin.  Chir.,  lvii.  485. 
5 Menard:  Gaz.  MeU  de  Paris,  1897,  S.  i.,  231. 
"Matherlie:  Ann.  de  Chir.  et  d'Orth.,  July,  1897,  218. 

7E.   H.  Bradford  and  Vose,  giving  bibliography,  Trans.  Am.  Surgical  Ass'n, 
1899. 


POTT'S    DISEASE:  47 

Paralysis. 

Present  before  the  operation .'!!  cases. 

Relieved  (complete  or  partial) 17  cases. 

Not  relieved 2      "■ 

Not  stated 8      " 

Appeared  (partial  only) 4  cases. 

General  condition. 

Reported  distinctly  improved 7  cases. 

Direct  effect  on  deformity  : 

At  the  time  of  operation,  stated  in 22!)  cases. 

Complete  correction 11!)  cases 

Incomplete  correction 94      " 

No  gain 10 

Result  three  months  later  (cases  with  some  gain) <;<>  cases. 

No  relapse 17  cases. 

Some  relapse 44 

Total  relapse 5 

It  is  obvious  from  the  inspection  of  any  series  of  pathological  speci- 
mens of  cured  cases  of  Pott's  disease,  that  the  diseased  tissue  is  replaced 
by  sound  bony  tissue  to  hold  the  disabled  column,  if  time  enough  is  given 
and  if  the  process  of  repair  has  not  been  overwhelmed  by  the  process  of 
destruction.  It  is  asserted  that  the  gap  between  the  bodies  of  the  verte- 
brae, which  is  caused  by  their  forcible  separation,  is  filled  in  very  rapidly 
with  new  bone.  This  gap  may  be  from  two  to  three  inches.  This  asser- 
tion, however,  is  not  supported  by  accurate  evidence,  nor  is  it  in  accord- 
ance with  pathological  facts. 

Sherman  (I.  c.)  reports  a  case  of  great  interest.  A  very  severe  de- 
formity in  a  boy,  eight  years  old,  in  the  dorsal  region  was  corrected  by 
routine  methods.  The  patient  died  three  months  after  operation,  and  an 
autopsy  showed  marked  separation  of  the  vertebral  bodies  but  no  attempt 
at  bony  repair.  Murray  quoted  two  autopsies  done  two  and  three  months 
after  forcible  correction,  in  neither  of  which  was  there  any  attempt  at  bony 
repair.1  Noble  Smith  reported  a  case  in  which,  two  and  oue-half  years 
after  the  correction  of  a  deformity  in  Pott's  disease  by  the  prone  position, 
a  soft  bony  growth  filled  in  the  gap  between  the  vertebrae,  but  it  was  so 
delicate  that  it  was  washed  away  during  maceration.2 

Two  questions  suggest  themselves:  the  first,  how  much  force  is 
needed  in  this  procedure;  the  second,  the  best  means  of  applying  the 
force.  The  amount  of  force  required  depends  upon  what  is  attempted. 
If  it  is  desired  to  break  up  any  ossification,  a  great  deal  of  force  would 
be  necessary;  when  the  amount  of  cicatrizing  ostitis  is  slight,  slight 
force  is  required.  When  the  power  is  used  to  a  mechanical  advantage, 
less  will  be  needed  for  the  required  correction.  It  is  for  this  reason  that 
the  plan  which  has  been  in  use  at  the  Boston  Children's  Hospital  for  the 

1Amer.  Jour.  Med.  Sciences,  May,  1898. 
sBrit.  Med.  Jour.,  February  19th,  1898. 


48 


ORTHOPEDIC    SURGERY. 


past  two  years  will  be  found  to  have  certain  advantages.  In  this  but 
little  force  is  employed,  and  that  well  under  control,  the  diseased  projec- 
tion being  used  as  the  central  resistant  point ;  and  the  weight  of  the  trunk 


Fig.  51.— Vertebral  Column  after  Forcible  Reduction.    (Sherman.) 

on  each  side  of  this  point  acts  as  a  straightening  force.  The  appliance 
by  which  this  correction  can  be  done  is  as  follows:  An  upright  which 
can  be  raised  or  lowered  by  an  adjustable  screw  is  furnished  with  a  steel 


Fig.  52.— Frame  for  Correction  of  Deformity  in  Pott's  Disease. 


top,  having  tips  so  arranged  as  to  steady  a  zinc  plate  equipped  with  holes, 
placed  so  as  to  press  at  each  side  of  the  vertebral  spines.  If  these 
plates  are  padded  and  placed  beneath  the  patient  in  such  a  way  that  they 
will  lie  on  each  side  of  the  spines  at  the  point  of  projection,  an  upward 
pressure  can  be  exerted  by  raising  the  upright  by  means  of  the  screw 
attachment.  If  this  is  raised  to  such  a  height  that  the  head  and  pelvis 
hang  from  a  suspended  trunk,  it  is  manifest  that  a  strong  force  is  exerted 


pott's  disease.  4'J 

to  straighten  the  spine  and  correct  the  curve.  This  can  be  increased  if 
necessary  by  a  traction  or  pressure  force  upon  the  limbs  or  upon  the 
head  and  shoulders. 

Goldthwait,  who  gmployed  the  method,  placed  steel  bars  to  lie 
close  to  the  spine  as  a  means  of  correcting  lordosis,  and  attached  the 
uprights  to  an  oblong  frame,  using  cross  bars  and  straps  as  a  sup- 
port for  the  trunk.  The  unusually  successful  cases  reported  by  him 
before  the  American  Orthopedic  Association  warrant  the  assertion  that 
the  method  is  equally  successful  with  that  requiring  the  employment 
of  great  force.  It  will  be  found  that  the  patient  suffers  but  little  dis- 
comfort, that  the  jacket  can  be  applied  readily,  and  in  practice  no  anaes- 
thetic is  used,  as  it  has  been  found  that  sufficient  force  can  be  applied 
without  discomfort,  and  it  is  believed  that  force  greater  than  this  would 
be  dangerous.  When  the  disease  is  seated  in  the  upper  dorsal  region,  it 
is  manifest  that  some  head  support  is  required,  and  this  can  be  fur- 
nished by  placing  felt  padding  about  the  neck,  and  including  this  in 
the  plaster  jacket  which  passes  above  the  shoulders  and  includes  the  head. 
Instead  of  this  the  various  forms  of  head  support  can  be  applied  to  the 
jacket,  or  repeated  jackets  should  be  applied  and  a  gradual  correction 
obtained  in  preference  to  the  employment  of  a  great  deal  of  force  at 
one  sitting.  The  amount  of  correction  obtained  at  each  sitting,  or  after 
a  number  of  sittings,  will  depend  necessarily  upon  the  pathological  con- 
ditions, the  complete  straightening  being  possible  but  not  practicable  in 
all  recent  cases. 

A  simpler  and  no  less  efficient  way  of  straightening  a  curved  spine, 
when  the  method  is  applicable,  may  be  described  as  follows:  The 
patient  is  placed  on  the  back  on  any  table.  A  sling  made  of  sufficiently 
firm  cloth  and  a  few  inches  in  width  is  passed  under  the  child  at  the 
greatest  prominence  of  the  projection.  Between  this  and  the  skin  a 
thick  layer  of  saddler's  felt  is  placed.  (A  hole  can  be  cut  out  in  the  felt 
or  later  in  the  jacket  to  protect  the  spinous  processes.)  This  sling 
should  pass  upward  on  both  sides  of  the  patient,  reaching  to  a  cross  bar, 
similar  to  that  used  in  the  ordinary  Sayre  suspension,  and  sufficiently 
wide  to  keep  the  ends  of  the  sling  from  crowding  the  patient's  ribs. 
The  cross  bar  can  be  attached  to  a  pulley  above  the  patient;  and  by  rais- 
ing the  cross  bar  the  patient  is  raised  to  the  point  at  which  it  is  desirable 
that  the  projection  should  be  corrected.  The  patient  can  be  raised  so 
that  the  weight  of  the  whole  trunk  acts  as  a  correcting  force;  and,  if 
necessary,  downward  pressure  or  a  downward  pull  can  be  exerted  upon 
the  pelvis  and  upon  the  shoulders,  or  downward  traction  can  be  used 
upon  the  arms,  head,  and  shoulders,  and  in  this  way  all  requisite  force 
may  be  used.  If  the  patient  is  raised  partially  from  the  table,  and  a  pil- 
low or  sand  bag  placed  under  the  head,  the  trunk  will  be  found  suffi- 
ciently raised  to  enable  the  surgeon  to  apply  plaster  rollers  in  the  ordi- 


50 


ORTHOPEDIC    SURGERY. 


nary  way.  The  plaster  bandages  can  be  applied  around  the  sling,  and 
the  sling  cut  off  at  the  place  of  emergence  of  the  bandages,  leaving  but  a 
slight  opening.  This  can  be  covered  by  an  extra  layer  of  bandage,  mak- 
ing the  jacket  perfectly  secure.  « 

The  advantages  of  this  method  are  chiefly  in  its  simplicity  and  its 
ready  use  without  any  complicated  apparatus.  In  fact,  a  broomstick  or 
bar  resting  on  two  high  pieces  of  furniture,  and  strong  bandages  or  cloth 


Fig.  53.— Apparatus  for  Correction  of  Pott's  Disease. 


as  a  sling  and  a  piece  of  felt  would  be  all  that  would  be  necessary  in  the 
application  of  a  correcting  plaster  jacket  by  any  surgeon  of  skill  and 
experience. ' 

It  is  evident  that  no  less  importance  is  to  be  placed  upon  the  retention 
of  a  spine  in  the  corrected  position  than  upon  the  correction  itself,  for  when 
a  cure  depends  upon  a  cicatricial  ostitis  solidifying  the  weakened  and  in- 
flamed tissues  which  have  replaced  the  normal  bone,  the  tendency  to  a  con- 
traction of  cicatrizing  tissues  before  ossification  has  taken  place  will  tend 
to  reproduce  the  curve,  even  if  thoroughly  corrected.  As  the  process  of 
ossification  of  cicatrizing  ostitis  is  not  a  rapid  one,  it  is  manifest  that 
protection  and  retention  will  be  required  for  some  time,  and  the  problem 
of  the  proper  appliance  is  not  a  simple  one,  as  the  apparatus  must  be  worn 


1 R.  T.  Taylor,  of  Baltimore,  has  recommended  an  excellent  method  of  the  applica- 
tion of  correction  of  the  spinal  curves  and  the  application  of  plaster  jackets  in  a 
sitting  position  (vide  Trans.  Amer.  Orthoped.  Association,  vol.  xii.). 


POTT  S   DISEASE. 


51 


for  months  and  even  years.  It  will  therefore  appear  that  the  use  of 
forcible  correction  in  i'ott's  disease  is  somewhat  more  limited  than  was 
at  first  supposed;  first,  by  the  judicious  selection  of  cases,  and  second,  by 
the  number  of  cases  in  which  the  after-treatment  can  be  properly  carried 
out,  for  it  is  manifestly  absurd   to  straighten  a  spinal  column,  exposing 


Fig.  54.— Pott's  Disease  before  Correction.    (Gold- 
thwait.) 


Fig.  55.— Same  Case  Twelve  Weeks  after  Correc- 
tion.   (Goldthwait. ) 


the  patient  to  a  certain  amount  of  risk,  and  later  to  allow  the  patient  to 
relapse  into  a  condition  as  bad  as  before  the  operation. 

It  is  believed  that  no  anaesthetic  is  necessary  if  cases  in  which  the  pro- 
cedure is  likely  to  be  beneficial  are  the  ones  subjected  to  the  treatment. 
The  after-treatment  requires  attention  for  years. 

Paralysis  is  often  helped  by  forcible  correction,  even  when  of  long 
standing,  and  a  mild  pressure  may  be  exerted  in  most  cases  without 
apparent  harm,  with  a  view  to  diminishing  deformity.  The  applicability 
of  the  operation  in  individual  cases  must  be  decided  on  the  grounds 
already  given.  It  is  obvious  that  in  no  event  is  the  method  suitable  to 
cases  in  which  complete  bony  ankylosis  has  taken  place,  as  recommended 
by  Calot.  In  the  opinion  of  the  writers  no  anaesthetic  is  necessary,  as 
no  degree  of  force  requiring  anaesthesia  should  be  used. 

It  is  a  question  of  judgment  in  each  case,  dependent  upon  the  situa- 
tion and  extent  of  curve,  whether  simple  recumbency  with  pad  pressure 
or  corrective  measures  are  needed. 


52 


ORTHOPEDIC    SURGERY. 


Treatment  by  Appliances 

(braces,  jackets/  aud  corsets)  aims  at  relieving  the  diseased  vertebrae 
of  at  least  part  of  the  body  weight  while  the  patient  goes  abont  with  as 
complete  fixation  as  possible. 

Treatment  by  Plaster  Jackets. — Suspending  a  healthy  person  by  the 
head  diminishes  the  physiological  curves  (cervical  and  lumbar  lordosis, 
dorsal  kyphosis),  and  the  spine  becomes  straight  so  far  as  its  formation 


I    / 


/ 


SITTING  LYING        MAMMOCK      SUSPENSION 

Fig.  56.— Variation  in  Curves  in  a  Case  of  Pott's  Disease  in  Different  Positions.    (Brackett.) 

will  allow.  The  spine  of  a  new-born  child  becomes  straight  by  suspen- 
sion, but  in  an  adult  the  shape  of  the  bones,  the  strength  of  the  liga- 
ments, and  the  tension  of  the  muscles  prevent  the  spinal  column  from 
becoming  perfectly  straight.  In  suspension  by  the  axillae  or  arms  the 
strain  comes  upon  the  latissimus  dorsi  muscles,  and  though  the  weight 
which  would  fall  upon  the  lower  part  of  the  spinal  column  is  removed, 
yet  the  curvatures  in  the  upper  part  of  the  spine  are  not  made  straight. 

In  suspension,  in  old  Pott's  disease,  it  is  only  the  physiological 
curves  which  are  obliterated ; 1  the  sharp  kyphosis  is  held  too  firmly  by 
adhesions  to  permit  correction.     In  earlier  cases  the  intervertebral  press- 


1  Anders:  Archiv  f.  klinische  Chirurgie,  1880,  iii.,  p.  558. 


POTT  S    DISK  ASK. 


53 


tire  must  be,  in  a  measure,  diminished  at  the  point  of  disease  by  suspen- 
sion ;  but  suspension  does  not  cause  a  disappearance  of  the  sharp  angular 
projections  at  the  point  of  disease,  although  the  kyphus  is  diminished  as 
shown  by  Brackett. 

The  undoubted  beneficial  effect  of  plaster  jackets  is  due,  not  to  the 
separation  of  the  affected  vertebrae,  but  as  a  fixation  support  in  an  im 
proved  position. 

It  was  originally  supposed  that  a  jacket  could  be  applied  so  as  to 
serve  as  a  means  for  holding  the  diseased  vertebrae  apart,  i.e.,  as  a  means 
of  distraction.      Suspension  having  pulled  the  vertebrai  apart,  a  jacket 


SITTING  HAMMOCK  SUSPENSION 

Fig.  57.— Variation  in  Tracings  of  Pott's  Disease.    (Brackett.) 


which  takes  its  base-bearing  on  the  pelvis  and  a  purchase  on  the  thorax, 
would  keep  these  portions  from  coming  together  by  a  vertical  support. 
These  ideas  are  erroneous.  Suspension  straightens  the  spinal  column 
somewhat  and  diminishes  antero-posterior  curves,  and  the  application  of  a 
plaster  jacket  prevents  the  column  from  bending  forward.  Plaster  jack- 
ets are  efficient  not  as  a  means  of  fixation  alone,  or  of  distraction,  but  as  a 
means  of  securing  comparative  fixation  in  an  improved  position.  The 
treatment  by  plaster  jackets  requires  care,  for  a  poor  jacket  does  harm 
rather  than  good  by  deceiving  the  physician  and  the  patient.  For  the 
proper  applying  of  plaster  jackets,  moreover,  a  careful  attention  to  detail 
is  necessary. 


54 


ORTHOPEDIC    SUROKRY 


l>andages  are  prepared  by  rolling  loose-meshed  cloth  in  dry  plaster- 
of-Paris.  The  cloth  to  be  chosen  is  that  capable  of  carrying  the  most 
plaster-of -Paris,  and  presenting  as  little  cloth  fibre  as  possible.  "  Crino- 
line' lining,''  which  has  been  washed,  will  be  found  to  answer  this 
purpose. 

Application  during  Suspension. — The  plaster  is  to  be  rubbed  into  the 
cloth  smoothly  and  to  be  freed  from  lumps  or  unevenness.  The  patient's 
clothes  are  removed  and  a  thin,  tightly  fitting-undershirt  is  applied,  put 

on  so  as  to  present  no  wrinkles. 
'■  The  patient  is  then  suspended ; 
the  head  is  secured  in  a  sling, 
which  is  attached  to  a  strong- 
cord   playing    in   a    pulley,   or 


-Sayre  Head-piece  for  Suspension  in  Pott's 
I  )isease. 


Fig.  59.— Appliance  for  Suspension. 


series  of  pulleys,  fastened  to  a  point  above  the  patient's  head.  An 
assistant  pulling  on  the  cord  raises  the  patient  so  that  the  heels,  and 
if  necessary  the  toes,  are  free  from  the  floor.  Tt  is  desirable  to  di- 
minish the  strain  upon  the  neck,  and  padded  loops  connected  with 
the  bar,  which  is  raised  by  the  cord  and  pulley,  can  be  passed  under 
each  axilla,  or  handles  may  be  held  in  each  hand,  connected  with  cords 
which  play  over  pulleys.     A  pull  on  the  cords  raises  the  patient.      Pads 


1  Various  forms  of  gauze  have  been  used  for  plaster  bandages ;  the  gauze  should 
be  entirely  free  from  glue  sizing,  and  if  stiffened  should  be  stiffened  with  starch.  If 
glue  sizing  is  present,  the  gauze  needs  to  be  washed,  otherwise  the.  quick  setting  of 
the  bandage  will  be  interfered  with.  The  cloth  should  be  free  from  oil  and  absorb 
water  quickly. 


POTT  S    DISK  ASK. 


55 


are  placed  over  the  crests  of  the  ilium,  and  a  large,  soft  pad  over  the 
abdomen.  This  latter  is  to  be  pulled  out  when  the  jacket  has  become 
hard,  and  prevents  too  great  a  pressure  on  the  abdomen. 

The  bandages  are  placed  singly  on  end  in  water  and  kept  immersed 
until  they  are  thoroughly  wet  (i.e.,  until  air  bubbles  no  longer  rise  in  the 
water  from  the  immersed  bandage)  and  are  then  wound  smoothly  around 
the  patient. 

If  the  plaster  is  fresh  and  of  the  best  quality,  it  should  harden  in  live 
minutes.  The  hardening  can  be  hastened  by  putting  salt  or  alum  in  the 
water,  but  this  makes  the  plas- 
ter somewhat  more  brittle. 
After  the  plaster  is  hard  or 
nearly  hard,  the  patient  is  to 
be  placed  on  a  soft  flat  sur- 
face, care  being  taken  not  to 
crack  the  plaster  in  so  doing. 


PIG.  60.— Frame  for  Application 
of  Jackets  during  Recumbency, 
Ready  for  Use. 


Fig.  61.— Plaster  Jacket.    (Children's  Hospital 
Report.) 


The  abdominal  pad  is  then  removed,  and  the  edges  of  the  jacket  are 
smoothed  down  and  cut  off  if  they  press  uncomfortably  on  the  thighs  or 
axillae. 

It  is  important  that  the  jacket  should  be  strong  in  front  as  well  as 
behind,  and  should  be  wound  as  high  as  possible  in  front,  in  order  to 
prevent  the  spinal  column  from  falling  forward.  If  the  jacket  become 
broken  or  softened,  it  should  be  removed  and  another  applied. 


56  ORTHOPEDIC   SURGERY. 

Chafing  can  usually  be  prevented  by  careful  padding  on  each  side  of 
the  prominent  vertebral  process.  For  this  purpose  saddler's  felt,  cut  of 
the  appropriate  thickness,  and  sewed  to  the  undervest  in  the  proper 
place,  will  answer. 

If  the  disease  is  in  the  cervical  region,  the  plaster  bandages  can  be 
carried  up  around  the  back  of  the  head  and  neck  and  under  the  chin,  leav- 
ing the  face  and  upper  part  of  the  head  exposed,  and  so  fixation  and  sup- 
port may  be  obtained  in  that  part  of  the  vertebral  column.  This  method 
of  fixation  has  certain  manifest  disadvantages  in  lack  of  cleanliness,  clum- 
siness, and  unsightliness,  but  it  is  thorough  and  furnishes  an  excellent 
support  and  is  by  no  means  uncomfortable  for  the  patient. 

With  the  proper  application  of  the  plaster  jacket  began  a  new  era  in 
the  treatment  of  Pott's  disease,  and  for  this,  much  honor  is  due  to  Dr. 
Sayre,  who  was  so  influential  in  bringing  this  useful  measure  to  the 
notice  of  the  profession.  It  brought  a  ready  means  of  treatment  within 
the  reach  of  thousands  of  patients  who  could  not  have  been  helped  by 
the  prevalent  methods  of  treatment. 

Ajwlication  during  Recumbency  on  the  Face. — The  patient  is  laid 
prone  with  the  arms  above  the  head  on  a  hammock,  which  consists  of  a 
stout  cloth  a  little  wider  than  the  child,  stretched  over  the  ends  of  a 
rectangular  gas-pipe  frame.  One  end  of  this  cloth  is  attached  to  the  up- 
per end  of  the  frame  and  does  not  move.  The  other  end  is  attached  to 
a  movable  bar  connected  with  the  other  end  of  the  frame  by  a  rope. 
By  a  ratchet  this  bar  can  be  pulled  upon  and  the  tension  of  the  cloth 
regulated.  The  hammock  may  be  made  very  tight  or  allowed  to  sag  to 
any  extent.  In  this  way  hyperextension  of  the  spine  may  be  produced 
as  desired. 

The  child  is  laid  on  the  hammock,  prepared  as  described  above. 
The  cloth  is  cut  along  the  sides  of  the  child's  body  longitudinally  and 
the  parts  not  under  the  child's  body  are  drawn  aside  and  fastened.  The 
plaster  rollers  are  then  applied,  including  both  child  and  hammock. 
Just  before  finishing  the  hammock  should  be  cut  across  just  above  the 
top  of  the  jacket,  and  the  child  suspended  by  the  arms  or  head  by  an 
assistant  and  the  upper  turns  put  on  with  the  upper  spine  hyperextended. 
This  prevents  the  falling  forward  of  the  upper  part  of  the  jacket,  which 
will  happen  otherwise.  Portable  frames  of  gas-pipe  may  be  made  for 
this  method  of  application.  This  method  has  several  advantages.  It 
places  the  spine  in  a  better  position  than  does  suspension  and  diminishes 
the  kyphus.  This  has  been  demonstrated  by  Brackett. !  It  is  less  ter- 
rifying to  children,  and  fainting  does  not  occur  as  in  suspension.  The 
hammock  frame  can  easily  be  taken  from  place  to  place.  It  is  not  so 
available  for  cases  with  much  lateral  curvature  as  suspension.      Plaster 

'Trans.  Anier.  Orth.  Assn.,  vol.  viii. ,  p.  160. 


POTT  S    DISK  ASK.  .>( 

jackets  may  be  split,  furnished  with  lacings  and  applied  and  removed  at 
will;  they  lose  thereby  a  part  of  their  efficiency,  as  they  may  be  im- 
properly reapplied  by  the  patient. 

But  with  careful  parents  and  attention  plaster  jackets  lose  but  Little 
of  their  efficiency  if  they  are  carefully  split  down  the  front  and  removed 
before  they  dry.  If  they  are  cut  they  should  at  once  be  placed  in  the 
same  shape  that  they  were  in  before  removal  and  tightly  bandaged  to 
keep  them  from  warping,  as  they  will  do  if  let  alone. 

The  most  acceptable  form  of  jacket  is  one  applied  over  a  seamless 
woven  shirt.  These  shirts  are  made  very  long  and  reach  the  knees;  one 
of  them- is  put  on  the  patient  and  the  jacket  applied  over  it.     The  lower 


Fig.  63.— Method  of  Applying  a  Plaster  Jacket  in  Recumbency.    (Children's  Hospital  Report.) 


part  of  the  shirt  is  then  turned  up  over  the  outside  of  the  jacket  and 
reaches  to  the  top  of  it.  It  is  there  stitched  to  the  upper  part  of  the 
shirt  along  the  upper  edge  of  the  jacket.  This,  however,  is  not  done 
until  the  jacket  has  been  removed,  by  splitting  it  down  the  front  and 
gently  springing  it  open.  The  edges  of  the  cut  are  stitched  with  leather 
and  a  row  of  hooks  is  provided  on  each  side  with  which  to  lace  it 
together.  A  jacket  is  thus  provided,  which  is  covered  inside  and  outside 
with  soft  woollen  material,  which  can  be  removed  for  purposes  of  clean- 
liness and  reapplied  to  the  patient,  who  should  be,  of  course,  suspended 
or  laid  on  the  face  for  each  reapplication. 

As  a  substitute  for  plaster  jackets,  corsets  are  made  of  leather,  felt, 
wood,  aluminum,  celluloid,  papier-mache,  silicate  of  potash,  etc.  The 
plaster  jacket,  which  is  applied  in  the  usual  way,  is  removed  with  care, 
so  as  to  preserve  its  shape.  A  plaster  mould  is  taken,  and  on  this  as  a 
form  a  corset  is  made  of  leather  (which  when  wet  can  be  stretched 
tightly  over  the  form),  by  winding  bandages  or  strips  of  paper  soaked  in 


58 


ORTHOPEDIC    SURGERY. 


silicate  of  potash  or  paste  about  the  mould.  After  this  has  become 
hard,  it  can  be  split  and  furnished  with  eyelets  and  lacings;  it  can  then 
be  applied  on  the  patient,  who  is  suspended,  as  in  the  application  of  a 
plaster  jacket. 

Rawhide  stretched  over  a  east,  thoroughly  dried  and  left  until  hard- 
ened, furnishes  a  corset  which  is  both  light  and  firin.  The  process  of 
manufacture  requires  attention  and  detail.  The  same  is  true  of  a  jacket 
made  of  strips  of  sheet  celluloid  partially  softened  in  acetone.  Both  of 
these  corsets  curl  unless  equally  dried,  before  using,  on  the  inner  and  outer 

side.  Gauze  soaked  in  a  paste 
made  by  dissolving  celluloid  in  ace- 
tone is  serviceable,  and  made  with- 
out great  difficult}^.  The  jacket 
which  the  writers  have  found  to 
be  the  most  readily  made  is  of  a 
dry  leather  oxhide,  dressed  so  as 
to  be  freed  from  oil,  stretched  over 
a  cast  after  being  made  soft  by 
soaking,  and  when  dried,  stiffened 
by  melted  bayberry  wax. 

In  the  upper  dorsal  and  cervical 
region  it  is  necessary  either  to  add 
to  the  plaster  jacket  an  appliance 
for  securing  the  head  (the  varieties 
of  which  will  be  mentioned  later), 
or  to  carry  the  plaster  jacket  over 
the  shoulders  and  neck. 

A  plaster  collar  applied  simply 
to  the  neck,  and  not  to  the  trunk, 
does  not  give  sufficient  support  except  in  disease  of  the  upper  cervical 
vertebrae,  though  it  has  been  occasionally  used. 

The  jury  mast  consists  of  a  bent  rod  of  steel  running  up  from  the 
jacket,  following  the  curve  of  the  neck  and  head  to  a  point  above  the 
top  of  the  head.  To  the  end  of  this  rod  is  attached  a  cross  bar  which 
carries  a  head  sling.  The  lower  end  of  the  jury  mast  terminates  in  a 
metal  framework,  which  is  incorporated  in  the  jacket.  By  raising  the 
head  sling  the  head  can  be  pulled  upward.  But  it  is  very  difficult  in 
practice  to  keep  up  continuous  traction  on  the  head  in  this  way,  and  the 
inconvenience  and  unsightliness  of  the  apparatus  are  objectionable. 

The  chief  objection  to  the  treatment  of  caries  of  spine  with  a  perma- 
nent plaster  jacket  is  in  the  uncleanliness.  Removable  jackets  and  cor- 
sets are  not  firm.  As  a  base  for  head  supports  in  the  upper  dorsal  and 
cervical  regions  a  corset  is  not  readily  applied  and  is  more  unsightly  than 
a  well-fitted  appliance;  but  in  the  mid-dorsal  and  upper  lumbar  region 


Fig.  63.-  Paper  Jacket.    (Children's  Hospital 
Report. ) 


pott's  disease. 


59 


the  permanent  plaster  jacket  must  be  regarded  as  the  most  efficient  am- 
bulatory fixative  appliance. 

When  a  lateral  deviation  of  the  spinal  column  is  present  with  Pott's 
disease,  the  jacket  is  preferable  to  any  brace. 

In  disease  which  is  very  low  down,  the  jacket  is  often  a  more  efficient 
and  comfortable  mode  of  treatment.  For  careless  and  ignorant  patients 
a  jacket  which  is  not  removable  is  far  preferable  to  any  apparatus  which 
they  can  misuse.  Moreover,  the  cheapness  of  the  jacket  brings  it  within 
reach  of  many  people  who  would  otherwise  have  to  go  without  treatment. 

Treatment  by  Steel  Apjrtiances. — The  basis  of  ambulatory  treatment 
of  Pott's  disease  in  the  subacute  or  convalescent  stage  is  fixation  of  the 


Fig.  fi4.— Jury-mast  before  Incorporation. 


Fig.  (55.— Jury-mast  and  Plaster  Jacket. 


spine  in  as  advantageous  a  position  as  possible.  This  is  done  by  means 
of  stiffened  corsets,  but  can  also  be  done  by  means  of  a  properly  made 
appliance. 

As  the  chief  motion  of  the  spine  to  be  guarded  against  is  the  forward 
motion,  the  principle  of  the  appliance  is  that  of  an  antero-posterior  sup- 
port. This  was  first  efficiently  applied  by  Dr.  C.  F.  Taylor,  of  New- 
York,  as  a  method  of  thorough  treatment,  as  it  involves  skill  and  anatom- 
ical and  pathological  knowledge. 

The  construction  and  application  of  a  brace  should  be  superintended 
directly  by  the  surgeon,  and  not  relegated  to  an  instrument-maker.  The 
details  relative  to  the  future  result  are  fully  as  important  as  the  applica- 


60  ORTHOPEDIC    SURGERY. 

tion  of  a  splint  in  any  fracture,  for  the  result  will,  in  a  great  measure, 
depend  on  the  accuracy  of  adjustment.  For  the  construction  of  a  splint 
a  cardboard  tracing  of  the  hack  should  be  made. 

The  simplest  anteroposterior  apparatus  consists  of  two  uprights  of 
annealed  steel,  three-eighths  or  one-half  of  an  inch  in  width  and  thick 


Fig.  66. -Bivalve  Plastic  Splint  for  Pott's  Disease.    (H.  L.  Taylor.) 

enough  to  be  rigid.  The  gauge  numbers  of  the  steel  as  to  thickness 
should  be  from  eight  to  twelve.  These  uprights  should  reach  from  just 
above  the  posterior  superior  iliac  spines  to  about  the  level  of  the  second 
dorsal  vertebra.  The  uprights  are  joined  together  below  by  an  inverted 
U-shaped  piece  of  steel  which  runs  as  far  down  on  the  buttock  as  pos- 
sible without  reaching  the  chair  or  bench  when  the  patient  sits  down. 


POTT  S   DISEASE. 


61 


As  a  guide  to  this  it  should  be  remembered  that  they  must  not  extend 
down  as  far  as  the  tuberosities  of  the  ischium.  Or  the  brace  may  end  in 
a  waist-baud.  The  uprights  are  joined  above  by  another  U-shaped  piece, 
the  upper  ends  of  which  should  pass  over  to  the  anterior  aspect  of  the 
shoulders,  or  rather  to  the  root  of  the  neck.  In  most  cases  a  cross  bar 
at  the  level  of  the  axillae 
should  be  added. 

The  uprights  should  be 
far  enough  apart  to  sup- 
port the  transverse  proc- 
esses of  the  vertebra?,  and 
not  the  spinous  processes. 
They  should  be  bent  ac- 
cording to  a  cardboard 
tracing  of  the  back,  taken 
as  described,  and  then  ad- 
justed to  the  back.  The 
neck  and  bottom  pieces 
should  be  cut  out  in  card- 
board in  pattern.  The 
whole  should  then  be  riv- 
eted together  and  tried  on 
the  patient,  who  should  be 
lying  on  his  face.  Any 
alteration  necessary  in  the 
curves  of  the  steel,  in  order 
to  have  the  appliance  fit 
closely  to  the  back  along 
its  whole  length,  can  be 
made  Avith  wrenches.  The 
brace  can  be  wound  with 
strips  of  Canton  flannel, 
faced  with  hard  rubber, 
covered  with  chamois,  or 
covered  smoothly  with 
leather,  An  accurate  fit  is 
essential,  the  covering  is 
merely  a  matter  of  detail 

Accurately  fitting  pad  plates  covered  with  felt  and  leather  or  hard 
rubber  are  needed.  In  some  instances,  at  the  points  of  greatest  pressure 
the  bars  of  the  brace,  if  well  padded,  answer  every  purpose.  Buckles 
are  needed  at  the  ends  of  the  neck  piece,  at  a  level  with  the  axilla,  op- 
posite the  middle  of  the  abdomen,  and  at  the  lower  end  of  the  brace, 

If  properly  designed  the  appliance  will  press  firmly  at  the  deformity, 


Fig.  67  -Bivalve  Splint.    (H.  L.  Taylor  ) 


62 


ORTHOPEDIC    SURGERY. 


i.e.,  the  pad  plates  and  pressure  should  be  uniform  at  this  point  and 
closely  fitted  to  the  contour  of  the  deformity  in  all  planes.  The  appli- 
ance will  also  touch  necessarily  at  the  top  and  bottom,  but  the  chief  press- 
ure should  be  at  the  kyphus.  Variations  from  this  type  of  construction 
will  naturally  be  of  use.  Nicety  of  workmanship  in  the  manufacture  of 
a  brace  is  of  relatively  secondary  importance.     The  essential  is  that  it 

should  be  mechanically  efficient  in 
meeting  the  indications  of  fixation. 
The  construction  of  the  brace  does  not 
necessarily  involve  expensive  work- 
manship, and  need  not  be  anything 
beyond  the  skill  of  a  village  black- 
smith.    It    should    be    borne  in  mind 


Fig.  68. 


-Diagram  of  Antero-postertor  Sup- 
port ;  Side  view. 


Fig.  69. 


-Diagram  of  Antero-posterior  Support;   Bad: 

View. 


that,  besides  accuracy  of  fit  and  proper  design,  it  is  of  importance  that 
the  apparatus  be  stiff  enough  not  to  yield  as  the  weight  of  the  trunk  falls 
upon  it,  inasmuch  as  yielding  involves  intervertebral  pressure.  This  is 
true  not  only  of  the  uprights,  but  also  of  the  band.  A  stiff  appliance,  if 
properly  fitted,  can  be  made  as  comfortable  as  a  yielding  one,  and  is 
much  more  efficient. 

An  error  in  accuracy  of  fit  may  be  sufficient  to  furnish  insufficient 
protection  and  cause  relapse.     Moreover,  it  is  necessary  that  the  patient 


POTT  S    DISEASE. 


63 


should  be  seen  often  enough  to  keep  the  brace  fitting  accurately,  for  the 
deformity  may  increase  or  diminish  at  anytime.  In  such  a  case  the 
brace  becomes  inefficient. 

It  is,  of  course,  essential  that  the  trunk  be  properly  secured  to  the 
brace.  This  can  be  done  in  part  by  means  of  an  apron,  which  covers  the 
front  of  the  trunk,  the  abdomen,  and  the  chest,  reaching  from  the  clavi- 
cles nearly  to  the  symphysis  pubis.  The  apron  is  provided  with  webbing 
(non-elastic)  straps,  which  are  fastened  into  buckles  attached  to  the 
brace.  Padded  straps,  passing  from  the  top  of  the  brace  around  the 
arms,  under  the  axillae,  and  attached  to 
buckles  in  the  middle  of  the  brace,  help 
to  secure  it;  but  the  scapulae,  being  mov- 
able, cannot  be  relied  upon  alone  to  fix  the 
trunk,  and  the  apron  must  be  furnished 
with  straps  at  the  top,  which  pass  over  the 
shoulders  to  buckles  in  the  top  of  the  brace. 

In  adults  it  is  often  convenient  to  have 
the  apron  split  down  the  front  and  pro- 
vided with  webbing  straps  and  buckles, 
so  that  the  patient  can  adjust  it  himself 
by  tightening  the  straps  in  front. 

To  secure  a  proper  hold  upon  the  upper 
segment  of  the  body  in  dorsal  disease  some 
unyielding  and  rigid  chest  piece  is  neces- 
sary. Taylor's  chest  piece  acts  by  means 
of  hard-rubber  pads  at  the  upper  part  of 
the  chest,  connected  by  a -steel  rod,  which 
keeps  the  brace  closely  against  the  back. 
The  pads  of  the  chest  piece  may  be  made 
of  hard  rubber  and  fit  in  below  the  clavi- 
cles, where  they  cause  no  discomfort  and 
restrict  the  chest  movements  less  than  the 
apron,  besides  affording  more  definite  support.  Other  forms  of  chest 
piece  are  in  use.  A  simple  one  can  be  made  over  a  plaster  cast  of  the 
chest  by  shaping  leather  which  is  afterward  stiffened  by  treatment  with 
hot  wax.  This  may  be  extended  upward  to  support  the  chin  in  cases  of 
high  dorsal  disease.  To  this  hard  leather,  steel  buckles  may  be  attached. 
Schapps  has  described  an  efficient  chest  piece. 

The  brace  should  be  worn  day  and  night,  and  removed  daily  that  the 
back  may  be  bathed.  While  the  brace  is  off,  the  patient  should  lie  on 
the  face  or  the  back.  On  no  account  should  he  sit  erect.  The  back, 
after  being  washed,  should  be  rubbed  with  alcohol  and  then  powdered 
with  face  powder,  corn  starch,  or  Pear's  fuller's  earth.  The  brace 
should  then  be  applied  and  buckled  tightly  into  place. 


Fig.  70.— Taylor  Back-brace.    (Children's 
Hospital  Report.) 


04 


ORTHOPEDIC   SURGERY. 


Chafing  of  the  back  is  sometimes  unavoidable  in  summer.  When  a 
severe  chafed  spot  forms,  the  brace  must  be  removed  for  the  time  and  the 
child  should  lie  Hat  in  bed  until  the  ulcer  heals.  A  smooth  covering  of 
leather  is  least  irritating  to  the  skin.  The  brace  may  be  worn  over  a 
cloth  or  underVest,  but  is  least  likely  to  chafe  if  applied  directly  over  the 
skin. 

1  )r.  Judson  formulates  a  general  rule  which  may  serve  as  a  guide  in 
the  treatment  of  Pott's  disease  by  rigid  apparatus,  especially  in  all  forms 


Fig.  71.— Taylor  Back-brace  Applied.    (Children's 
Hospital  Report.) 


Fig.  72.— Pressure  Marks  from  Taylor  Back-brace. 
(Children's  Hospital  Report.) 


of  the  antero-posterior  support.  The  rule  reads :  "  The  apparatus  may 
be  considered  as  having  reached  the  limit  of  its  efficiency  if  it  makes  the 
greatest  possible  pressure  on  the  projection  compatible  with  the  comfort 
and  integrity  of  the  skin." 

Certain  braces  have  a  tendency  to  "ride-up,"  and  the  neck  pieces, 
instead  of  lying  closely  to  the  shoulders,  project  upward  in  a  most  un- 
sightly way.  In  general,  this  does  not  occur  in  braces  which  fit  accu- 
rately. Sometimes,  however,  it  is  most  troublesome,  and  in  these  cases 
padded  perineal  straps  can  be  added  which  are  attached  to  the  apron  in 
front  and  to  the  lower  end  of  the  brace  behind.      They  are,  however,  a 


pott's  disease.  65 

source  of  much  annoyance  to  children,  in  urination  especially,  and  are 
to  be  avoided  if  possible.  The  apron  will  sometimes  be  found  to  cut  over 
the  anterior  superior  spines  of  the  ilium  and  also  under  the  arms,  and 
must  be  properly  padded. 

In  applying  the  brace  the  patient  should  lie  upon  his  face,  and 
the  apron  be  spread  under  him.  The  brace  should  then  be  placed  in 
position  upon  the  bare  back,  or  upon  a  thin,  smooth  cloth  without 
wrinkles,  and  the  apron  strapped  to  it  as  tightly  as  is  possible.  The 
more  tightly  the  two  are  strapped  together,  the  more  thorough  is  the 


Fig.  73.— Apron  for  Taylor  Back-brace.    (Children's  Hospital  Report.) 

fixation.  The  position  of  the  straps  and  their  number  will  vary  in  cases 
according  to  the  situation  of  the  disease,  etc.  The  brace  must  of  course. 
if  it  is  to  exert  pressure,'  always  be  straighter  than  the  spine. 

A  troublesome  complication  in  the  use  of  the  antero-posterior  brace  is 
the  presence  of  a  lateral  curve  in  the  vertebral  column ;  this  has  been 
mentioned  as  an  occasional  complication  of  Pott's  disease.  The  brace 
fits  when  the  child  lies  down,  biit  when  he  sits  up,  the  column  leans  to 
one  side  again,  and  it  is  of  course  impossible  for  the  brace  to  fit  as  be- 
fore. Fortunately,  this  symptom  passes  slowly  away  as  efficient  support 
is  afforded  to  the  column,  and  then  the  brace  fits  again.  Meantime  it  is 
best  to  apply  the  brace,  bending  up  one  neck  piece  and  bending  the  other 
5 


66 


ORTHOPEDIC    SURGERY 


down  to  make  the  top  of  the  brace  set  squarely,  or  to  apply  a  plaster 
jacket,  which  is  ordinarily  the  most  available  mode  of  treatment  under 
these  conditions;  it  is  also  best  to  keep  the  patient  in  a  recumbent  posi- 
tion as  much  as  possible  until  the  deformity  improves. 

The  application  of  the  therapeutic  principle  of  fixation  in  the  best 
possible   position  varies   according   as   the  disease   involves  the  upper, 

middle,  or   lower  parts  of  the 
spinal  column. 

In  the  upper  region,  as 
elsewhere,  it  is  desirable  to 
prevent  the  weight  of  the  head 
from  falling  upon  the  diseased 
bodies  of  the  vertebrae. 

An  efficient  arrangement  is 
one  used  by  Dr.  C.  F.  Taylor, 
of  New  York;  an  ovoid  steel 
ring  passes  around  the  neck, 
made  so  that  it  can  open,  and 
be  secured  when  closed,  and 
arranged  so  that  it  can  serve 
as  a  rest  for  the  chin,  and  so 
that  pressure  can  also  be  ex- 
erted on  the  occiput.  This 
collar  has  at  the  front  a  hard- 
rubber  chin  piece  accurately 
shaped  to  the  chin,  and  may 
have  at  the  back  a  stiff  piece 
of    sole  leather    projecting  up 


Fig.  74.— Antero-posterior  Support  Ap- 
plied.   (Dr.  H.  L.  Taylor.) 


Fig.  75.— Taylor's  Chest  Piece. 


from  the  back  of  the  ring.  This  steadies  the  head  and  prevents  the 
pressure  of  the  occiput  against  the  back  of  the  headpiece.  This  col- 
lar at  the  back  plays  on  a  pivot,  allowing  lateral  motion  of  the  head. 
The  pivot  is  attached  to  the  usual  back  brace,  and  can  be  raised  or 


pott's  disease. 


07 


lowered,  as  it  is  desired,  to  increase  or  diminish  the  upward  pressure 
on  the  head.  This  appliance  requires  care  and  skill  in  application,  and 
is  useless  unless  properly  fitted. 

Other  forms  of  head  support  have  been  tried  from  time  to  time. 
Some  of  them  have  been  useful. 

A  head  support,  devised  by  Goldthwait,  affords    excellent    fixation. 
Its  construction  is  evident  from  the  figure,  and  it  is  serviceable  in  cases 
in  which  there  is  excessive  sensi- 
tiveness of  the  spine,  due  to  cer- 
vical or  very  high  dorsal  disease. 

Collars  of  various  sorts,  un- 
attached to  any  other  appliance, 
have  been  used,  which,  pressing 
on  the  chin  and  occiput  above, 
and  on  the  clavicles,  sternum, 
and  shoulders  below,  transfer  the 
weight  in  part  from  the  interme- 
diate cervical  vertebrae  and  check 
the  forward  bending  of  the  cer- 
vical region.  These  collars  can 
be  made  of  plaster-of-Paris,  but 
are  cumbersome  and  unsightly. 
The  most  easily  made  collar  is 
that  invented  by  the  late  H.  0. 
Thomas,  of  Liverpool.  Leather 
stuffed  with  sawdust  is  the  most 
available  material  of  which  to 
make  them.  They  may  also  be 
made  of  tin,  silicate  of  potash, 
wire  netting,  or  any  of  the  other 
materials  mentioned  in  speaking 
of  corsets. 

A  convenient  way  of  makiug  these  collars  is  by  taking  a  piece  of  stout 
webbing,  long  enough  to  go  loosely  around  the  neck,  and  winding  it  with 
sheet  wadding  or  oakum  until  it  is  padded  sufficiently.  Then  it  should 
be  covered  with  a  bandage  outside,  and  the  ends  of  the  webbing  should  be 
buckled  together.  The  patient  wears  the  collar  a  few  days,  and  then  as 
the  padding  becomes  matted  down  new  padding  is  added  until  the  collar 
is  the  desired  size  and  shape.  It  is  then  sent  to  a  harnessmaker  to  be 
covered  with  leather.  In  this  way  a  much  more  satisfactory  result  is 
obtained  than  by  sending  measures  to  a  harnessmaker  in  the  first  place. 

In  all  forms  of  head  supports,  if  worn  for  a  long  time,  a  certain 
amount  of  recession  of  the  chin  takes  place.  The  nature  of  this  is  not 
clearly  understood,  but  the  growth  of  the  lower  jaw  is  in  a  measure  tem- 


FiG.  76.— Taylor  Back-brace  Applied,  Showing  Chest 
Piece.    (Children's  Hospital  Report.) 


68 


ORTHOPEDIC    SURGERY. 


porarily  interfered  with,  and  the  front  teeth  in  the  lower  jaw  in  severe 
cases  do  not  articulate  with  those  of  the  upper.  The  distortion  results 
from  the  continued  use  of  any  form  of  head  support,  and  is  more  liable 
to  occur  the  more  efficient  the  support.     The  jaw  gradually  resumes  its 

shape  after  removal  of  the 
head  support. 

Collars,  however,  lack 
in  steadiness,  and,  in  order 
to  secure  accurate  fixation 
of  the  head,  they  should  be 
connected  with  uprights 
which  extend  below  and  are 
attached  to  the  trunk.  They 
are  adapted  only  to  the  treat- 
ment of  cervical  disease  of 
a  character  not  very  acute. 
When  torticollis  is  present 
as  the  result  of  irritation, 
treatment  by  recumbency  is 
advisable. 

It  is  hard  to  say  just 
when  the  need  for  a  head 
support  begins.  In  general, 
if  the  disease  is  above  the 
fourth  dorsal  vertebra,  a 
headpiece  is  indicated. 
Sometimes,  if  the  disease 
is  lower  down,  pain  or  dis- 
tortion makes  it  evident 
that  a  head  support  is  need- 
ed there  also,  or  it  may  be 
necessary  to  add  one  if  the 
brace  does  not  make  satis- 
factory pressure  at  the  seat 
of  deformity. 

Selection  of  a  Method  of  Treatment. — In  the  selection  of  mechanical 
supports  the  choice  will  lie  between  some  of  the  fixed  corsets  of  plaster- 
of-Paris  (or  the  variations  of  that  form  of  corset  fixation)  and  the  antero- 
posterior supports  of  steel. 

When  careful  and  skilled  attention  can  be  applied  to  the  construc- 
tion, attention,  and  needed  alteration  of  a  brace,  it  will  be  found  of  great 
efficiency  in  the  treatment  of  Pott's  disease  in  the  convalescent  stage. 
It  should  be  remembered,  as  has  been  shown,  that  it  is  impossible  to  pry 
the  vertebrae  apart  by  leverage,  as  no  apparatus  could  be  worn  which 


Fig.  77.— Taylor  Back-brace  with  Head 
dren's  Hospital  Report.) 


upport. 


POTT'S    DISEASE. 


69 


would  sustain  absolutely  the  weight  of  the  upper  part  of  the  trunk  from 
falling  forward.  The  antero-posterior  support  is  to  be  regarded  as  an  ap- 
paratus which  modifies  rather  than  relieves  intervertebral  pressure  by  the 
principle  of  leverage. 

The  chief  objection  to  the  use  of  mechanical  appliances  as  a  method 
of  treatment  is,  that  care  and  special  skill  are  required,  not  only  in  th<; 
application  of  braces,  but  in  the  inspection  and  management  of  the 
cases. 

Faulty  Appliances. — Unless  an  appliance  works  in  the  way  the  indi- 
cations of  the  disease  demand,  it  is  inefficient,  and  it  is  on  account  of 


Fm.  78.  Fig.  79. 

Figs.  78  and  79.— Taylor  Back-brace  with  Head  Support  Applied.    (Children's  Hospital  Report.) 

faulty  construction  that  appliances  have  often  been  found  of  so  little  use. 
A  most  common  fault  is  that,  in  order  that  the  appliance  may  be  light, 
the  steel  uprights  are  flexible  and  give  under  pressure.  It  is  evident 
that  any  appliance  which  allows  bending  forward  of  the  spine  at  the 
point  of  disease  does  not  relieve  the  pressure  when  relief  is  most  needed. 
A  second  fault  is  that  the  trunk  is  often  not  thoroughly  fixed  by  the 
straps,  etc.,  of  the  appliance.  If  this  is  the  case,  the  brace  becomes 
simply  a  splint  of  steel  laid  upon  the  back,  and  not  a  therapeutic  agent. 


70 


ORTHOPEDIC    SURGERY. 


The  exact  situation  of  straps  must  vary;  they  should,  however,   make 
pressure  as  high  up  and  as  low  down  on  the  trunk  as  possible.     If  elastic 

straps  are  used,  the  value  of 
the  appliance  is  impaired  in 
proportion  to  the  elasticity. 

Operations  on  the  Diseased 
Vertebrce.  —  Operative  meas- 
ures have  been  recommended 
for  the  direct  examination  of 


Fig.  80.— Form  of  Head  Support  for  Cervical  Caries. 
(Goldthwait.) 


Fig.  81.— Bent  Wire  Chin  Support, 
dren's  Hospital  Report.) 


the  diseased  vertebral  bodies  and  the  removal  or 
drainage  of  the  diseased  bone.  It  must  be  re- 
membered that  in  any  event  the  vertebral  bodies 
are  more  or  less  inaccessible,  and  that  such 
operations  are  not  likely  to  prove  of.  benefit  as 
routine  measures. 

In  the  cervical  region  the  anterior  surfaces  of 
the  bodies  of  the  vertebrae  may  be  reached 
either  through  the  mouth,  by  a  lateral  inci- 
sion, or  by  incision  in  the  back  of  the  neck. 
Through  the  mouth  the  operating  space  is 
small,  the  proceeding  difficult  on  account 
of  the  anaesthetic,  and  the  dangers  of  in- 
fection are  evident.  This  method  makes 
accessible  only  the  second,  third,  and 
fourth  vertebral  bodies.  The  lateral 
method  is  preferable.  An  incision  is 
made  along  the  posterior  border  of  the 
sternomastoid  muscle;  the  sternomastoid 
and  omohyoid  are  raised  and  the  space 
made   by   the  splenius    and   omohyoid  is 


FIG.   ¥&.— Thomas'  Leather  Collar. 


POTT'S  disease. 


I. 


reached.  The  dissection  is  carried  through  the  longua  colli,  and  the  ver- 
tebral arteries  are  avoided. 

A  second  method  of  reaching  the  cervical  vertebrae  from  the  side  is 
by  an  incision  at  the  level  of  the  larynx,  passing  down  to  the  lateral 
edge  of  the  thyroid  body  close  to  the  larynx,  and  dividing  the  tissues 
internal  to  the  common  carotid  artery. 

The  incision  behind  the  sternomastoid  muscle  is  to  be  preferred. 

In  the  dorsal  region  several  methods  have  been  proposed  for  reaching 
the   vertebrae.      Schaeffer's  incision  is  on  a  line  with  the  side  of  the 


Fig.  83.— Young's  Head  Support.    (Young.) 


Fig.  84.— severe  Deformity  in  Pott's  Dis- 
ease, Showing  the  Sinking  Forward  of  the 
Upper  Segment  Uncontrolled  by  Brace. 


spinous  processes.  It  uncovers  the  top  of  the  transverse  processes  of  the 
affected  vertebrae  and  the  base  of  the  corresponding  ribs.  The  ribs  are 
divided  at  the  level  of  the  tuberosities,  the  transverse  processes  are  then 
removed,  the  bone  having  been  freed  from  its  attachments  by  blunt  dis- 
section . 

Vincent  modifies  this  proceeding  by  reaching  the  bodies  of  the  verte- 
brae on  both  sides  of  the  spinal  column,  boring  a  hole  through  the  verte- 
bras and  passing  a  drain.      Menard  by  a  transverse  incision  exposes  the 


72  ORTHOPEDIC    SURGERY. 

spinal  end  of  the  rib,  which  corresponds  to  the  apex  of  the  deformity. 
He  excises  the  corresponding  transverse  process,  denudes  the  rib  of  peri- 
osteum, cuts  it  off  about  two  inches  from  its  spinal  end,  and  takes  out 
that  part  of  the  rib.  Sometimes  it  is  necessary  to  resect  a  second  rib. 
He  follows  then  the  periosteal  canal,  which  leads  to  the  tuberculous 
focus;  this  is  generally  opened  by  the  extraction  of  the  rib;  the  focus  is 
then  washed  out  and  drained. 

In  the  lumbar  region  the  procedure  advocated  by  Treves  in  1884  is 
the  best.  An  incision  is  made  from  the  twelfth  rib  to  the  ilium,  two 
and  one-half  inches  outside  of  the  median  line ;  the  incision  reaches  to 
the  border  of  the  quadratus  lumborum  and  the  tips  of  the  transverse  proc- 
esses should  be  felt.  The  dissection  is  carried  down  to  the  psoas  mus- 
cle ;  some  of  the  fibres  of  this  muscle  are  detached  with  care  from  one 
transverse  process.  The  finger  introduced  reaches  without  difficulty  the 
anterior  surface  of  the  vertebral  bodies.  The  finger  can  strip  up  the 
psoas  muscle  through  this  incision  and  explore  the  vertebral  bodies. 
The  vertebral  canal  should  not  be  opened. 

These  operative  procedures  are  rarely  indicated  in  tuberculous  disease 
of  the  spine,  except  to  drain  increasing  abscesses  where  thorough  drainage 
is  otherwise  impossible. 

Abscess. — The  most  common  and  important  complication  in  Pott's 
disease  is  the  development  of  an  abscess.  Although  it  is  found  that  the 
frequency  of  abscess  is  diminished  by  efficient  treatment,  yet  its  devel- 
opment may  be  dependent  upon  uncontrollable  pathological  conditions. 
Abscesses  may  be  treated  by  expectancy  or  by  operation. 

(1)  Expectancy. — Under  proper  treatment  early  abscesses  may  sub- 
side and  be  absorbed  without  detriment  to  the  patient.  Expectancy  may 
be  aided  by  aspiration. 

When  abscesses  increase  rapidly,  or  for  any  reason  seem  an  injury  to 
the  patient,  incision  is  to  be  considered. 

(2)  Operation. — Incision  of  an  abscess  should  be  made  under  thorough 
aseptic  precautions,  and  if  these  are  thoroughly  carried  out  and  complete 
drainage  secured,  the  procedure  is  devoid  of  undue  risk ;  but  it  must  be 
remembered  that  owing  to  the  depth  of  the  origin  of  abscesses  in  Pott's 
disease  perfect  drainage  is  not  always  as  easily  furnished  as  in  more 
superficial  abscesses.  It  is  therefore  desirable,  especially  in  adults,  to 
delay  incision  longer  than  would  otherwise  be  surgically  indicated. 

In  retropharyngeal  and  cervical  abscesses,  however,  this  is  not  true, 
as  drainage  can  ordinarily  be  readily  secured.  In  dorsal  abscesses  an 
incision  in  the  back  is  frequently  sufficient;  but  in  some  instances  it  will 
be  necessary  to  perform  costo-transversectomy  to  secure  perfect  drainage. 
In  lumbar  and  iliac  abscesses  it  is  usually  necessary,  owing  to  the  depth 
of  their  origin,  to  incise  both  in  front  and  behind,  which  can  be  done  with 
care  without  opening  the  peritoneal  cavity. 


POTT'S   DISEASE.  7.', 

If  an  operation  is  done  with  proper  precautions  it  is  attended  with 
little  risk  of  sepsis.  It  is  not  to  be  expected,  however,  that  simple  in- 
cision and  drainage  will  close  the  abscess  in  most  cases.  On  tin;  con- 
trary, their  tendency  is  to  discharge  almost  indefinitely,  and  this  must 
be  borne  in  mind  in  advocating  operation  when  it  is  not  indicated  by 
pressure  effects  and  the  distention  of  the  abscess. 

The  most  usual  place  for  opening  psoas  abscesses  is  in  the  groin  or 
iliac  fossa.  Better  drainage  is  secured  if  a  counter  opening  is  made  in 
the  loin.  This  can  easily  be  done  by  carrying  a  urethral  sound  up  ami 
back  from  the  lower  wound  and  making  it  prominent  in  the  luin  and  then 
cutting  down  on  it.  It  must  be  remembered  that  communication  in  front 
of  the  vertebral  canal  may  exist  between  the  psoas  sheath  of  one  side 
and  that  of  the  other. 

Very  often  an  abscess  which  has  advanced  so  far  as  to  appear  as  a 
swelling  in  the  groin  may  be  opened  in  the  back  and  a  second  opening  in 
the  groin  may  or  may  not  be  necessary.  An  incision  is  made  along  the 
side  of  the  lumbar  vertebras  just  outside  the  transverse  processes  and 
carried  down  through  the  quadratus  lumborum  muscle  until  the  abscess 
sac  is  reached.  The  abscess  sac  can  usually  be  distinguished  without 
difficulty  and  is  made  tense  by  pressure  in  the  groin.  It  is  evacuated  by 
an  incision  at  the  bottom  of  this  wound.  In  opening  the  abscess  in  this 
way  at  the  seat  of  the  disease  it  may  be  possible  with  a  curette  to  remove 
a  part  of  the  diseased  body  of  the  vertebrae.  This,  however,  must  be 
done  with  very  great  care.      To  be  of  any  use  it  must  be  thorough. 

A  retropharyngeal  abscess  is  best  opened  by  passing  into  the  mouth 
a  bistoury  wound  to  within  half  an  inch  of  its  point  with  cotton,  and 
cutting  freely,  using  the  finger  as  a  guide.  The  child  should  be  held 
face  downward  in  order  that  the  pus  may  not  enter  the  trachea,  and 
plenty  of  swabs  should  be  at  hand  to  keep  the  mouth  clear,  for  the  gush 
of  pus  is  sometimes  considerable. 

Treatment  of  Psoas  Contraction. — When  flexion  of  one  or  both  thighs 
has  come  on,  it  is  not  likely  to  diminish  spontaneously,  and  if  the  condi- 
tion is  allowed  to  go  untreated,  such  contractions  may  become  permanent. 

A  permanent  contraction  of  one  or  both  psoas  muscles  with  the  thigh 
flexed  is  a  serious  deformity.  If  it  exists  on  both  sides,  the  patient  can 
walk  only  with  the  trunk  held  nearly  horizontal.  If  it  is  unilateral,  it 
leads  to  a  very  serious  disability,  requiring  in  most  cases  the  use  of  a 
crutch,  for  the  diseased  spine  cannot  be  flexed  to  allow  the  foot  to  reach 
the  ground  in  walking  as  it  does  when  right-angled  flexion  of  the  thigh 
exists  as  a  result  of  hip  disease.  For  these  reasons  it  is  desirable  to 
attack  psoas  contraction  with  very  vigorous  measures,  which  afford  a 
prospect  of  averting  any  permanent  contraction. 

In  the  early  stages  the  child  should  be  put  to  bed  on  a  frame.  A 
light  extension  should  be  applied  to  the  leg,  and  the  pulley  should  be 


T4  ORTHOPEDIC    SURGERY. 

gradually  lowered  until  the  leg  is  straight  and  the  flexion  gone.  In  cases 
in  which  the  flexion  has  existed  only  a  few  weeks  or  months,  this  is  gener- 
ally easily  accomplished  in  two  or  three  weeks.  If  not,  or  if  a  more  rapid 
method  is  desired  in  the  first  instance,  the  child  should  be  anaesthetized 
and  the  leg  straightened  by  force  and  retained  by  plaster-of-Taris  or  some 
retentive  apparatus.  If  this  cannot  be  done  with  the  use  of  moderate 
force,  it  is  better  to  divide  and  cut  the  fascia  and  the  contracted  bands — 
an  operation  which  cannot  often  be  done  thoroughly  subcutaneously,  for 
there  are  many  deep  bands. 

The  deformity  is  almost  sure  to  return  if  the  patients  are  allowed  to 
go  about,  and  they  should  either  be  kept  on  a  frame,  or  an  arm  should 
be  extended  down  from  the  brace  or  the  jacket  to  keep  the  thigh  fully 
extended.  Finally,  subtrochanteric  osteotomy  may  be  necessary  in  severe 
cases,  but  it  should  not  be  done  until  after  recovery  from  the  Pott's  dis- 
ease. 

Paralysis. — With  the  beginning  of  paralysis,  or  even  in  the  case  of 
much  exaggerated  knee  reflexes,  it  is  best  to  put  the  patient  at  once  upon 
his  back,  as  in  this  way  the  full  development  of  the  paralysis  may  be 
prevented  and  its  course  shortened.  Recumbency  and  extension  by 
weight  seem  at  times  to  hasten  recovery. 

Traction  made  upon  the  head  and  legs,  as  described,  probably  adds  to 
the  efficiency  of  recumbency. 

Forcible  correction,  not  necessarily  with  an  anaesthetic,  offers  probably 
the  best  chance  of  improvement  in  early  paralysis ;  even  in  some  cases  of 
long  standing  it  has  proved  of  value.  Under  these  circumstances  the 
method  differs  in  no  way  from  that  described.  Two  or  three  attempts 
should  ordinarily  be  made  before  resorting  to  other  methods. 

Drugs  are  of  little  or  no  value,  and  it  is  not  possible  to  attach  much 
importance  to  the  use  of  the  cautery  or  of  counterirritants. 

Laminectomy.* ■ — If  these  measures  fail,  operative  treatment  must  be 
considered.  It  must,  however,  be  remembered  that  the  paralysis  tends 
toward  spontaneous  recovery  after  a  few  months,  so  that  ordinarily  opera- 
tion is  not  indicated  in  the  early  months  of  the  paralysis.  In  the  case  of 
rapidly  progressing  or  severe  paralysis,  however,  the  case  is  different. 
A  spicule  of  bone  or  an  intraspinal  abscess  may  be  the  source  of  pressure 
at  any  stage  of  the  disease,  and  in  such  cases  of  course  operation  is 
demanded.  In  cases  of  long  standing  in  which  the  paralysis  has  become 
very  extensive  and  has  involved  sensation,  and  possibly  the  sphincters 
of  the  bladder  and  rectum,  the  question  arises  as  to  whether  the  opera- 
tion is  likely  to  be  of  benefit,  or  whether  the  damage  to  the  cord  is  not 
already  irreparable;  but  in  these  cases  the  condition  is  so  serious  that 

1  De  F.  Willard  :  Trans,  of  Coll.  of  Phys.  of  Phila.,  March  Oth,  1889 ;  Annals  of 
Surgery,  July,  1889;  Wiener  med.  Presse.  1884.  42  ;  Ashhurst's  "Encycl.  of  Sur- 
gery," vol.  iv.  ;  British  Med.  Journ.,  August  11th,  1888. 


pott's  disease.  75 

most  patients  prefer  the  chance  of  relief  afforded  by  the  operation. 
Each  case  must,  however,  be  decided  on  its  individual  merits. 

The  operation  consists  in  cutting  down  upon  the  spinous  processes  in 
the  region  of  the  deformity,  the  incision  being  slightly  to  one  side  of  the 
centre,  so  that  the  resulting  cicatrix  will  not  be  unduly  pressed  upon  dur- 
ing recumbency.  All  the  soft  tissues  are  then  stripped  with  a  periosteal 
knife,  until  the  laminse  are  exposed.  The  spinous  processes  are  then 
removed  with  bone  forceps  over  the  affected  area.  Laminectomy  forceps 
are  then  used  to  cut  away  all  of  the  laminae  covering  the  cord  at  the  seat 
of  pressure.  The  dura  may  or  may  not  be  opened.  A  probe  is  then 
passed  up  and  down  the  spinal  canal,  to  be  sure  that  all  pressure  is  re- 
moved, and  the  wound  is  dressed.  The  patient  should  be  laid  on  the  face 
after  operation  if  it  is  more  comfortable. 

It  may  be  said  that  resection  of  the  laminae  of  the  vertebral  column 
is  an  operation  which  is  attended  with  a  risk  which  cannot  be  stated 
numerically.  But  at  the  same  time  brilliant  successes  at  times  follow 
the  operation,  so  that  it  holds  out  the  hope  of  relieving  cases  of  para- 
plegia which  would  otherwise  have  been  hopeless.  The  operation,  how- 
ever, has  no  place  in  the  treatment  of  Pott's  disease  until  the  con- 
servative measures  have  been  faithfully  tried  over  a  sufficient  period  of 
time — measures  which  in  most  cases  will  prove  efficient  and  successful 
in  the  relief  of  the  paralysis.  Immediate  improvement  is  not  to  be  ex- 
pected.1 

Prognosis  as  to  Time  in  Recovery. — No  reliable  statistics  exist  as  to 
the  amount  of  time  necessary  to  establish  a  cure  in  Pott's  disease.  The 
disease  varies  greatly  as  to  its  self-limitation  in  individuals,  and  accord- 
ing to  the  situation  and  extent  of  the  disease. 

Necessarily  there  will  be  a  difference  in  individual  cases  in  the  result 
of  treatment. 

Relief  from  symptoms  is  often  easily  obtained,  but  to  establish  a  com- 
plete cure  so  that  there  be  no  latent  disease  requires  protection  and 
treatment  for  years. 

Ketch,2  analyzing  seventy-five  cases  under  the  care  of  the  New  York 
Orthopedic  Dispensary,  found  that  the  general  time  of  obtaining  a  cure 
was  as  follows  on  the  average :  First  cervical  to  third  dorsal,  twenty-five 
months ;  fourth  dorsal  to  tenth  dorsal,  sixty-four  months ;  eleventh  dor- 
sal to  fifth  lumbar,  forty-seven  months. 

It  may  be  said  that,  as  the  bodies  in  the  cervical  region  are  smaller 

1  Medical  Record,  February  9th,  1889 ;  Wright :  Lancet,  July  14th,  1888,  64  ; 
British  Med.  Jour.,  August  11th,  1888,  ii.,  308,  323;  Glasgow  Med.  Jour.,  1884, 
xxii.,  65;  Glasgow  Med.  Jour.,  1886,  xxv.,  210;  Med.  Contemp.  Napoli,  1884,  i., 
520  ;  Lancet,  July  14th,  1888,  264  ;  Internal.  Jour.  Surgery  and  Antiseptics,  October. 
1888,  225;  Brit.  Med.  Journal,  April  20th,  1889. 

''Neidert:  Inaug.  Address,  Munich,  1886. 


76  ORTHOPEDIC   SURGERY. 

than  those  in  the  lumbar,  the  time  required  for  self-limitation  here  is 
shorter  than  in  the  lumbar  region.  In  the  latter  region,  also,  the  super- 
incumbent weight  is  a  more  important  factor  than  in  the  upper  part  of 
the  spine. 

Roughly  speaking,  it  is  always  possible  to  predict  a  course  of  treat- 
ment which  shall  last  not  less  than  three  years  and  probably  longer. 
Until  one  has  seen  the  frequency  with  which  relapses  occur  in  cases 
which  are  apparently  cured,  when  treatment  has  been  discontinued  too 
early,  it  is  impossible  to  appreciate  the  true  danger  in  an  early  discontin- 
uance of  treatment. 

The  occurrence  of  bony  formation  firm  enough  to  support  the  column 
in  its  weight-bearing  function  must  be  a  process  requiring  a  long  time 
for  its  completion,  to  judge  from  it  as  observed  elsewhere;  and  nowhere 
is  protection  more  urgently  demanded  during  convalescence  than  in  the 
vertebral  column.  This  is  especially  true  in  growing  children.  Cases 
of  supposed  cure  of  Pott's  disease  have  redeveloped  symptoms  at  the 
period  of  rapid  growth  at  the  approach  of  puberty.  It  should  especially 
be  borne  in  mind  that  protection  to  the  spine  may  be  needed  at  this 
period. 

Paralysis  in  Pott's  disease  shows  a  remarkable  tendency  to  recover. 
The  cases  investigated  by  Taylor  and  Lovett  gave  the  following  re- 
sults : 

Of  the  59  cases  analyzed,  39  patients  wholly  recovered,  3  recovered  in 
part,  5  died  of  intercurrent  affections,  and  in  12  cases  the  termination  is 
unknown.  That  is  to  say,  in  the  whole  number  of  cases  in  which  the  termi- 
nation Avas  known,  83  per  cent  recovered  wholly  from  the  paralysis.  The 
termination  was  unknown  in  so  many  cases  because  they  came  only  for 
consultation,  or  disappeared  from  observation  after  a  little  while,  or 
were  discharged  for  neglect.  The  bladder  and  rectum  were  noted  as  hav- 
ing been  paralyzed  in  8  cases,  and  here  the  percentage  of  recoveries  fell 
to  57,  in  the  cases  in  which  the  result  was  known.  The  arms  were 
affected  in  3  cases.  Of  these,  1  patient  recovered  wholly  and  the  other  2 
partly.  Muscular  rigidity  is  noted  in  5  cases,  of  which  2  patients  recovered 
wholly ;  but  it  was  undoubtedly  present  in  many  others.  When  the  par- 
alysis came  on  while  the  patient  was  under  treatment  (19  cases),  the  per- 
centage of  recoveries  was  100  in  the  17  cases  in  which  the  termination 
was  known.  The  average  duration  of  the  paralysis  in  all  these  cases  was 
a  little  less  than  one  year.  When  the  paralysis  came  on  under  treatment, 
the  average  duration  was  only  seven  months.  The  disappearance  of  the 
paralysis  was  gradual.  In  3  or  4  cases  the  recovery  followed  in  a  few 
days  or  weeks  after  the  evacuation  of  an  abscess,  and  in  1  case  the 
recovery  was  sudden  and  occurred  during  an  attack  of  measles,  after 
the  paralysis  had  lasted  two  years.  A  recurrence  of  the  paralysis  was 
not  uncommon,  having  occurred  in  6  cases — 4  patients  had  two  attacks, 


POTT'S   DISEASE.  77 

and  2  others  had  three.  The  intervals  between  these  recurrences  varied 
from  a  few  weeks  to  some  years.  Many  cases  of  improvement  or  cure 
of  paralysis  have  been  reported  after  forcible  correction. 

Recovery  may  take  place  after  complete  motor  paraplegia  even  with 
marked  sensory  impairment.  Paralysis  of  sensation  may  be  complete 
and  yet  recovery  result,  as  in  a  case  in  the  experience  of  the  writers  in 
which  the  loss  of  sensation  was  so  great  that  a  bandage  was  accidentally 
pinned  to  the  skin  without  pain  to  the  patient.  Complete  recovery  from 
paralysis  of  sensation  and  motion,  however,  occurred  in  a  year.  But 
paralysis  of  sensation,  especially  if  combined  with  paralysis  of  the  rec- 
tum and  bladder,  makes  the  prognosis  less  favorable. 

Prognosis  is  necessarily  made  much  less  favorable  by  the  existence  of 
amyloid  disease  of  the  viscera,  which  frequently  follows  long-continued 
suppuration. 

Although  the  prognosis  in  Pott's  disease  is,  as  in  all  diseases,  in  a 
measure  uncertain,  it  is  possible  to  promise  almost  certain  improvement 
from  proper  and  careful  treatment,  and  in  most  cases  to  anticipate  ulti- 
mate cure.  The  final  course  of  the  disease  must  in  many  cases  remain 
uncertain,  but  it  is  the  experience  of  the  writers  that  the  uncertainties  of 
prognosis  are  no  greater  in  this  than  in  other  grave  chronic  disorders. 

Treatment  must  be  thorough  and  long  continued  in  all  cases. 

Summary  of  Treatment. 

The  proper  treatment  of  Pott's  disease  is  not  the  application  of  any 
method,  the  use  of  any  corset  or  brace,  but  the  employment  of  such 
means  as  are  most  efficient  for  carrying  out  the  object  aimed  at.  A  brace 
is  useless  in  the  case  of  persons  unable  to  adjust  it;  a  plaster  jacket  ap- 
plied about  the  trunk  is  useless  in  disease  of  the  cervical  or  high  dorsal 
region.  Recumbency,  carried  to  a  point  of  depressing  the  patient's  men- 
tal and  physical  condition,  is  as  much  of  a  mistake  as  to  drag  a  patient 
about  who  is  anxious  to  lie  down. 

In  the  treatment  of  these  cases,  the  surgeon  should  be  familiar  with 
the  advantages  to  be  gained  by  all  methods,  and  should  employ  each  as 
the  case  may  demand,  and  for  such  a  length  of  time  as  the  circumstances 
of  the  case  may  require,  or  combine  the  different  methods  as  may  be 
advisable. 

In  a  general  way  he  may  formulate  to  himself  that :  in  acute,  painful 
cases  absolute  recumbency  with  fixation,  combined  with  traction,  is  the 
best  method  until  the  active  stage  of  the  disease  is  passed ;  in  middle 
and  lower  dorsal  Pott's  disease  an  immovable  plaster  jacket,  without 
head  attachment,  in  the  case  of  negligent  people. 

In  disease  of  the  cervical,  dorsal,  and  upper  lumbar  regions  some 
form  of  fixation  appliance  must  be  used  if  the  patient  is  not  recumbent. 


78  ORTHOPEDIC   SURGERY. 

The  choice  will  be  directed  by  the  circumstances  of  the  case  (amount  of 
care,  expense,  sensitiveness  as  to  appearance)  between  a  plaster  bandage, 
collars;  braces,  etc. 

In  the  lowest  lumbar  region  recumbency,  with  or  without  fixation  by 
extension,  constitutes  the  most  thorough  method  of  treatment.  Braces 
or  corsets  are  of  value  as  a  help  in  these  cases  for  fixation  during  recum- 
bency or  in  the  stages  of  convalescence,  and  when  recumbency  is  unad- 
visable. 

When  a  curve  is  marked  attempts  should  be  made  to  correct  it  in 
cases  in  which  bony  ankylosis  has  not  taken  place,  either  by  gradual 
means  or  the  application  of  moderate  force,  followed  by  fixation  in  a  cor- 
rected position,  with  recumbency. 

In  the  convalescent  stage  fixation  is  to  be  continued  until  cicatricial 
ostitis  has  restored  the  structure  of  the  vertebrae  to  a  normal  degree  of 
resistance. 

Properly  constructed  braces,  designed  so  as  to  apply  thorough  antero- 
posterior support,  with  fixation  in  an  improved  position,  form  a  method 
of  treatment  most  satisfactory  to  the  surgeon  capable  of  controlling  and 
inspecting  his  patient.  For  such  treatment,  however,  care  on  the  part 
of  the  attendant  of  the  patient,  and  ready  facilities  for  the  adjustment  of 
braces,  are  necessary. 

Whether  recumbency  for  a  time  is  required,  or  whether  ambulatory 
treatment  with  fixation  appliances  is  sufficient,  are  questions  of  judgment 
in  individual  cases. 


CHAPTER  II. 

LATERAL  CURVATURE  OF  THE  SPINE. 

Definition. — Frequency. — Predisposition  as  to  sex. — Clinical  history. — Stages  of  the 
affection. — Symptoms. — Varieties. —  Etiology.  —Pathology. — Diagnosis. — Prog- 
nosis.— Preventive  measures. — Treatment. 

By  this  term  is  understood  a  constant  deviation  of  the  spinal  column, 
or  a  portion  of  it,  to  either  side  of  the  median  line  of  the  body,  with  a 
resulting  distortion  of  the  trunk.  The  affection  has  also  been  called 
scoliosis,  and  rotary  lateral  curvature. 

In  French  it  is  known  as  Scoliose,  deviation  laterale  de  la  faille,  and 
in  German  it  is  called  Seitliche  Ruehg  ratsverkrumnmng . 

Lateral  curvature  is  either  congenital  or  acquired.  The  former  vari- 
ety, however,  is  rare ;  when  present,  it  is  either  a  result  of  foetal  rickets 
or  it  is  an  accompaniment  of  imperfect  development,  and  inequality  in 
the  formation  of  the  different  sides  of  the  trunk. ' 

Ketch,2  generalizing  from  229  cases,  concluded  that  lateral  curvature 
usually  begins  from  the  8th  to  the  15th  year;  in  52  per  cent  of  the  cases 
the  distortion  began  between  the  1st  and  12th  year.  In  41  per  cent  from 
the  12th  to  the  18th,  and  3  to  4  per  cent  from  the  18th  year  upward. 

Eulenburg,  in  1, 000  cases,  noted : 

78  between  birth  and  the  6th  year. 
216         "        the     6th  and  7th  years. 
564         "         "       7th  and  10th  years. 
107         "  "     10th  and  14th  years. 

35  after  the  14th  year. 

The  Frequency  of  the  Deformity. — The  frequency  of  scoliosis  may  be 
estimated  by  Drachmann's  figures,  who  found  in  1884,  on  examining 
28,125  school  children  in  Denmark  (16,789  boys,  11,386  girls),  368 
cases  of  scoliosis,  one  and  one-third  per  cent.  Fisher  states  that  of  3,000 
cases  of  deformity  brought  to  the  National  Orthopedic  Hospital  of  Lon- 
don 937  were  affections  of  the  spinal  column,  and  353  were  lateral  curva- 


1  Vogt:    "Moderne  Orthopsedik,"  p.  75;  Schreiber:  "  Orthopaedische  Chirurgie," 
p.  118. 

5  New  York  Medical  Journal,  April  24th,  1886. 


80  ORTHOPEDIC   SURGERY. 

ture.  Keren d  reports  900  scoliotic  patients  in  3,000  patients ;  Langgaard, 
700  in  1,000  cases;  Schilling,  000  in  1,000  (Schreiber).  These  figures, 
however,  taken  from  foreign  authorities,  do  not  necessarily  represent  the 
numbers  to  be  found  in  American  hospitals. 

Predisposition  as  to  Sex. — The  distortion  is  more  common  in  girls  than 
in  boys,  and  in  the  proportion  of  from  four  or  five  to  one. 

Ketch  found  189  females  and  40  males. 

Kolliker  found  577  females  and  144  males. 

Bernard  Eoth  found  in  200  cases,  183  girls;  Wildberger,  out  of  120 
cases,  1 01  girls ;  Berend  in  896  cases,  773  girls. 

Out  of  173  cases  collected  by  Adams,  151  were  females,  22  were 
males. 

Drachmann  found  the  proportion  of  girls  to  boys,  that  of  eight  to 
two. 

But  of  the  most  severe  forms  of  the  disease  there  are  more  males  than 
females,  and  it  is  possible  that  if  parents  were  as  solicitous  as  to  slight 
variations  in  the  figures  of  their  boys  as  of  their  girls,  the  statistics 
would  show  a  greater  proportion  among  boys  than  has  been  reported. 
In  the  lateral  curvatures  of  young  children  (under  five)  the  males  are  said 
to  equal  or  to  outnumber  the  females. 

Clinical  History. 

It  should  be  distinctly  borne  in  mind  that  lateral  curvature  is  not 
strictly  a  disease  so  much  as  a  distortion  of  growth. 

The  deformity  appears  and  is  developed  during  the  growing  years ; 
becoming  arrested,  as  a  rule,  at  the  end  of  the  period  of  growth. 

The  affection  may  be  divided  into  three  stages : 

1.  Initial  stage. 

2.  Stage  of  development. 

3.  Stage  of  arrest. 

Initial  Stage. — -The  affection  is  ordinarily  discovered  by  the  patient's 
mother  at  the  age  just  previous  to  puberty.  It  has,  however,  been  shown 
that  it  has  developed  earlier  than  this  in  a  majority  of  cases,  but  is  not 
recognized. 

Lateral  curvature  is  not  usually  seen  in  its  earliest  stage.  At  this 
period  of  it,  the  symptoms  are  so  slight  and  the  deformity  is  so  easily 
overlooked  that  the  surgeon  is  rarely  consulted.  The  patient  suffers  no 
inconvenience  at  this  stage,  and  as  the  child  is  at  an  age  (seven  to  ten) 
when  the  figure  is  not  carefully  scrutinized,  little  attention  is  paid  to  the 
slight  elevation  of  the  shoulder  or  projection  of  the  hip.  Upon  exami- 
nation, but  little  else  is  to  be  seen,  and  these  symptoms  disappear  on 
recumbency  or  suspension.  Tests  as  to  the  strength  of  the  muscles  some- 
times show  a  comparative  lack  of  muscular  force,  but  this  is  frequently 


LATERAL   CURVATURE    OF    THE    SPINE.  8] 

not  the  case.     A  careful   examination  often   discloses   a  peculiarity  in 
standing  or  sitting. 

State  of  Development.  —  In  a  majority  of  cases  when  the  surgeon  is 
consulted,  well-marked  development  of  the  distortion  has  already  taken 
place.  The  curves  are  either  flexible  curves,  that  is,  nearly  disappearing 
on  recumbency  of  the  patient,  or  when  the  patient  is  suspended;  or  are 
fixed,  when  little  change  of  the  curve  takes  place  in  removing  the  weight 
from  the  spinal  column.      Cases  vary  greatly  in  the  rate  of.  progress  made. 

The  muscular  system  mayor  may  not  be  well  developed;  but  in  a 
majority  of  cases  the  muscles  are  not  large  or  strong. 

In  the  early  periods  of  the  development  of  the  affection  there  is  rarely 
any  symptom  complained  of  except  the  annoyance  of  the  curvature,  due 
to  a  distortion  of  the  figure.  In  a  few  instances  of  growing  girls  with 
marked  impairment  of  strength,  some  thoracic  pain  may  be  felt,  and 
fatigue  on  exertion  in  walking  or  standing.  In  addition  to  this,  sensi- 
tiveness and  burning  sensations  in  the  back  may  be  found,  though  these 
latter  are  more  properly  attributable  to  a  disordered  condition  of  the 
nervous  system,  classed  as  neurasthenia,  than  directly  to  the  lateral 
curve. 

The  period  during  which  the  curvature  of  the  spine  may  develop  is 
indefinite,  as  well  as  are  the  rate  and  extent  of  the  development.  It  is 
impossible,  in  the  present  stage  of  our  knowledge,  to  predict  the  amount 
of  increase  or  the  permanency  of  arrest. 

The  liability  to  increase  is  greatest  during  the  growing  years.  But 
cases  of  severe  curvatures  will  be  seen  in  which  development  has  slowly 
continued  during  the  years  of  younger  adult  life. 

Stage  of  Convalescence  and  Arrest.  —  While  it  is  certainly  true  that  the 
time  when  a  curve  may  be  regarded  as  arrested  is  not  easily  recognized, 
an  examination  of  a  large  number  of  untreated  cases  justifies  an  opinion 
that  spontaneous  arrest  takes  place  in  a  very  large  number  of  the  slighter 
cases,  without  further  development  of  the  deformity.  Even  in  many  of 
the  severer  types  of  the  deformity  patients  will  be  observed  who  go 
through  adult  life  Avithout  any  increase  of,  or  inconvenience  from,  the 
deformity. 

No  sharp  distinction  as  to  stages  of  development  and  arrest  can  be 
made,  but  the  classification  of  this  sort  has  its  value  in  considering  treat- 
ment. 

In  general,  it  may  be  said  that  the  initial  stage  corresponds  to  child- 
hood and  the  approach  of  puberty ;  the  stage  of  development  extends 
from  the  period  of  commencing  puberty  to  the  establishment  of  growth ; 
and  the  stage  of  arrest,  or  quiescence,  includes  a  period  after  completion 
of  osseous  development. 
6 


82 


ORTHOPEDIC  SURGERY. 


Symptoms 


Pain.  The  symptoms  depend,  in  general,  upon  the  amount  of  distor- 
tion, but  this  rule' is  not  an  absolute  one,  as  in  certain  individuals  slight 
irritation  produces  a  greater  amount  of  pain  than  in  others  less  deformed. 

Painful  symptoms  are  as  a 
rule  not  common  in  the 
affection. 

The  symptoms  of  pain 
are  of  three  classes  : 

1st.  Those  due  directly 
to  the  altered  muscular  or 
ligamentous  strain. 

2d.  Those  due  to  the 
abnormal  pressure  from 
distorted  ribs  or  vertebrae 
upon  nerves,  or  to  altera- 
tion of  the  size  and  shape 
of  the  thorax,  and  displace- 
ment of  viscera. 

3d.  Iseur  asthenic 
symptoms  from  a  lack  of 
vitality,  superinduced  by 
the  limitations  as  to  exer- 
cise and  activity,  conse- 
quent on  the  deformity. 

Cases  of  slight  curves 
are  practically  free  from 
symptoms  of  pain,  and  in 
the  milder  types  of  the 
deformity,  at  the  stage  of 
arrest,  no  symptoms  are 
complained  of  if  the  patient  is  in  good  health ;  if,  however,  the  health 
becomes  enfeebled,  slight  neuralgic  pain  in  the  sides  of  the  thorax  is 
occasionally  felt.  This  is  usually  accompanied  by  parsesthesia,  or  hy- 
peresthesia in  certain  parts  of  the  back,  in  the  upper  dorsal  or  lumbar 
region;  but  in  the  severest  types  of  the  deformity,  symptoms  directly 
due  to  the  distortion  may  be  observed,  viz.,  neuralgic  pains  from  abnor- 
mal pressure  upon  nerves  and  from  undue  strain  upon  ligaments  and 
fasciae,  occasioned  by  distorted  attitudes. 

The  pain,  which  is  usually  located  in  the  lumbar  region  and  the 
thighs,  is  worse  after  fatigue,  and  is  relieved  in  a  measure  by  removing 
the    superincumbent    weight,    but   it    is   often    impossible   to   determine 


Fig.  85.— Right  Lateral  Curvature.    (Weigel.) 


LATERAL   CURVATURE    OF    THK    SI'INK. 


83 


whether  these  symptoms  are  due  directly  to  tlie  curvatures  or  to  a  con 
comitant  neurasthenia. 

Tenderness  on  pressure  is  never  present  in  pure  lateral  curvaturn,  and 
when  found  it  is  an  evidence  of  nervous  depression. 

General  Symptoms.- — Interruption  in  the  functions  of  the  liver,  stom- 
ach, and  intestines  is  mentioned  by  Adams  as  occasionally  sec-n  in  severe 


-^-v--.::^^^ 


**"' 


IP*      V  "^ 

Fig.  86.— Long  Right  Convex  Dorsal  Curve.  Fig.  87.— Double  Lateral  Curvature. 


cases.  Shortness  of  breath  also  occurs  as  well  as  pain  in  the  stomach, 
loss  of  appetite,  and  indigestion. 

In  the  severest  cases  a  lack  of  deposit  of  fat  in  the  subcutaneous  tis- 
sue will  be  noticed,  and  the  patients  are  thin,  even  though  they  may  be 
in  relatively  good  health. 

The  neurasthenic  symptoms  are  chiefly  manifested  by  indisposition 
to  exertion,  vague  complaints  of  pain  and  discomfort,  and  tenderness  in 
the  back.  These  symptoms  are  rarely  as  marked  in  lateral  curvature  as 
in  the  pure  forms  of  spinal  irritation,  but  they  may  be  added  to  the 
symptoms  directly  due  to  the  distortion. 


84 


ORTHOPEDIC    SURGERY. 


In  many  of  the  severest  forms,  the  patients'  lives  are  made  miserable 
by  a  variety  of  symptoms  probably  referable  to  impaired  circulation, 
feeble  digestion,  lack  of  energy,  and  limited  powers  of  respiration.  The 
symptoms  are  in  part  due  to  the  mechanical  compression  of  the  deformed 
thorax,  and  in  part  to  a  lowered  condition  of  the  nervous  system,  as  is 

seen  in  ordinary  cases  of  neur- 
asthenia. 

Distortion.  — T  h  e  chief 
symptom  of  lateral  curvature 
is  necessarily  the  distortion, 
which,  even  when  not  severe 
enough  to  occasion  discomfort, 
is  often  a  source  of  mortifica- 
tion and  annoyance  to  the  pa- 
tient. 

The  distortion  is  not  limited 
to  a  simple  curvature  of  the 
spine,  but,  as  will  be  described 
later,  to  this  is  added  a  twist- 
ing of  the  whole  trunk ;  or,  in 
other  words,  there  is  both  a 
curvature  and  a  torsion  on  a 
vertical  axis. 

Curvature. — The  curvature 
of  the  spinal  column  varies  in 
degree,  situation,  and  extent. 

The  variations  are  so  great 
that  no  two  curvatures  are  pre- 
cisely alike,  as  is  evident  from 
the  accompanying  illustrations. 
There  are,  however,  common 
types,  which  it  is  convenient 
to  bear  in  mind  in  considering 
the  subject  of  treatment. 
If  one  lateral  curve  occurs  in  the  middle  region  of  the  spinal  column, 
two  other  compensating  curves  are  of  necessity  developed  in  opposite 
directions,  one  above  and  one  below  the  deformity,  in  order  that  the  head 
be  kept  erect  and  in  the  median  line.  These  compensating  curves  may 
or  may  not  be  of  pathological  significance. 

For  practical  purposes  the  lateral  curvature  consists  of  a  single  curve, 
which  may  be  situated  in  different  parts  of  the  column.  In  some  in- 
stances one  of  the  compensating  curves  is  of  an  equal  prominence  with 
the  so-called  primary  curve;  in  which  case  the  spinal  column  will  present 
the  S-shaped  curve  which  is  characteristic  and  which  is  illustrated  in 


Fig.  88.— Front  View  of  Lateral  Curvature.  Showing 
Prominence  of  Left  Mamma  in  Right  Dorsal  Convex 
Curvature. 


LATERAL   CURVATURE    OF   THE   SPINE. 


83 


the  accompanying  pictures.     In  oilier  cases,  what  is  termed  the  compen- 
sating curve  may  become  more  marked. 

The  curves  are  often  termed  either  dorsal  or  lumbar,  but  they  are 
rarely  limited  exactly  to  these  portions  of  the  spinal  column;  in  most 
instances,  also,  the  curves  are  not  typical;  the  upper  curve  may  be  so 
long  as  to  include  all  of  the  dorsal  and  upper  lumbar  vertebrae,  so  that  the 
prominent  hip,  due  to 
the  sinking  away  and 
rotation  forward  of  the 
lower  ribs  on  the  side  of 
the  concavity,  may  not 
be  the  right,  but  the 
left  hip — although  the 
right  shoulder  is  raised. 
Again,  the  lower  curve 
may  be  so  long  as  to  in- 
vade nearly  the  whole 
of  the  dorsal  region,  the 
compensation  taking 
place  in  the  upper  part 
of  the  cervical  region. 

In  both  these  vari- 
eties of  curves,  compen- 
sating curves,  so  called, 
are  necessarily  present. 
They  may  be  so  slight 
as  not  to  attract  atten- 
tion, or  they  may  consti- 
tute a  curve  of  equal 
severity  with  the  upper 
or  lower  curves,  forming 
a  double  curve. 

Furthermore,  when 
the  curves  are  in  the 
flexible  stage  it  is  diffi- 
cult to  determine  which  is  the  more  important  one;  but  after  osseous 
changes  have  taken  place,  the  most  important  curves  become  fixed,  and 
these  are  the  curves  which  demand  most  attention.  This  is  partly  due 
to  the  attitude  in  which  the  column  is  placed,  and  partly,  probably,  to 
a  lack  of  resistance  of  tissues  of  certain  parts  of  the  spinal  column. 

Cervical  Curvature. — The  cervical  or  high  dorsal  curves  are  the  least 
common  forms  of  lateral  curvature,  except  when  associated  with  torti- 
collis. 

This  curvature  may,  however,  occur  primarily ;    when  it  does,  it  is 


fig. 


'.—Left  Lumbar  Curvature,  Showing  Prominence  of  Hip. 
(Weigel.) 


si; 


ORTHOPEDIC   SURGERY. 


more  commonly  accompanied  by  a  long  compensatory  lower  curve.  There 
is  invariably  elevation  of  one  shoulder  and  an  inclination  of  the  axis  of 
the  head  to  the  side  of  the  concavity  of  the  cervical  curve. 

Dorsal  Gurvature.—Th.e  most  common  dorsal  curve  is  with  the  con- 
vexity to  the  right.  In  these  cases  the  right  shoulder  will  be  raised,  the 
right  shoulder  blade  will  project  backward  more  prominently  than  the  left, 
and  will  be  at  a  higher  horizontal  level  and  farther  from  the  median  line  of 


0 


Fig.  90.— Dorsal  Right  Convex  Curve. 


Fig.  91.— Slight  Flexible  Upper  Dorsal  Right 
Convex  Lateral  Curvature. 


the  trunk.  The  back,  just  below  the  scapula,  will  be  more  rounded  back- 
ward on  the  right  side,  and  more  flattened  on  the  left,  and  the  left  shoul- 
der will  be  held  down.  In  front,  in  well-marked  cases,  the  breast  may 
be  more  prominent  on  the  left  than  on  the  right  side. 

In  addition  to  the  curve  there  may  be  a  tendency  to  incline  the  whole 
trunk  to  the  right  side.  When  this  is  the  case,  the  right  arm,  when 
hanging,  will  be  free  from  the  side,  while  the  left  arm,  when  hanging 
down,  necessarily  strikes  the  hip. 

There  is  also,  unavoidably,  ?,  change  in  the  outline  of  the  sides  of  the 
back.  The  sides,  instead  of  being  symmetrical,  as  seen  from  the  back, 
will  be  different,  the  left  side  of  the  outline  will  be  unnaturally  straight, 
and  on  the  other  more  than  normally  hollowed. 


LATERAL   CURVATURE    OK1   THIO    SI 'INK. 


ST 


Lumbar  Curvature. — The  lower  dorsal  or  lumbar  curvature  manifests 
itself  by  a  prominence  of  one  of  the  hips;  most  frequently  the  right, 
sometimes  the  left.  In  well-marked  cases  there  is  also  a  fulness  in  the 
back  on  the  left  side,  above  the  crest  of  the  ilium;  and  a  corresponding 
flattening  on  the  right  side.  In  front  the  umbilicus  is  at  the  side  of  the 
median  line.  The  most  common  lumbar  curve  is  with  the  convexity  to 
the  left. 

A  difference  in  the  outlines  of  the  two  sides  of  the  back,  already 
mentioned,  is  also  seen  in  this  form  of  curvature. 

A  sharp  clinical  distinction  between  lumbar  and  lower  dorsal  curves 
is  not  practicable,  as  they  resemble  each  other  in  regard  to  the  resulting 


Fig.  92.— Projection  of  Shoulder  in  Right  Convex  Dorsal 
Curvature. 


Fig.  93.— Upper  Dorsal  Curvature. 


distortion.  A  combination  of  lumbar  and  dorsal  curves  will  of  course 
present  the  features  of  both  varieties,  but  the  distortion  of  the  most  pro- 
nounced curve  predominates.     If  the  curves  are  equal,  a  double  curva- 


88 


ORTHOPEDIC   SURGERY 


ture  is  said  to  exist,  in  which  case  the  leaning  to  one  side  is  not  so 
marked  as  in  long,  single,  dorsal  curves. 

The  more  common  curves  are  those  indicated  with  the  upper  convex- 
ity to  the  right  and  the  lower  convexity  to  the  left,  but  the  curves  may 
be  reversed ;  whan  this  is  the  case,  the  distortion  will  be  correspondingly 
altered. 

Localization.  —  Some  writers  regard  the  lumbar  scoliosis  as  the  chief 


Fig.  94.— Anteroposterior  Curve 
in  Lateral  Curvature. 


Fig.  95.— Severe  Lateral  Curvature  (Untreated). 


curve,  and  as  most  common.  The  question  may  be  regarded  as  not 
settled,  though  for  clinical  purposes  it  may  be  accepted  as  a  fact  that  the 
dorsal  curve  is  the  one  most  frequently  requiring  treatment. 

Limping. — In  certain  very  severe  cases  the  distortion  of  the  vertebral 
column  is  so  great  that  the  pelvis  is  secondarily  tilted,  and  by  this  one 
leg  is  rendered  shorter  than  the  other  for  practical  purposes  and  a  more 
or  less  marked  limp  may  be  caused. 

In  721  cases,  Kolliker1  found  that  391  were  in  the  dorsal  region;  208 
of  these  were  with  the  convexity  to  the  right  and  183  with  the  convexity 
to  the  left.     Two  hundred  and  twenty-two  cases  showed  double  prominent 


Centralbl.  f.  Chir.,  No.  21,  188(3. 


LATERAL  CURVATURE   OF  THE   SPINE.  89 

c\irves,  and  of  these  172  were  with  the  upper  curve  convex  to  the  right 
and  the  lower  curve  convex  to  the  left. 

Forty-two  and  two-thirds  per  cent  of  the  number  examined  by  Drach- 
mann,  92  per  cent  of  those  reported  by  Eulenburg,  84  per  cent  according 
to  Adams,  and  81  per  cent  according  to  Heiner,  presented  curves  in  the 
upper  dorsal  region  with  the  convexity  toward  the  right.  Lorenz  and 
Drachmanu  think  that  the  lumbar  lateral  curvature  with  the  convexity 
toward  the  left  is  more  frequent  than  has  been  thought.  Lorenz  found 
in  163  cases  62  lumbar  curves  and  64  dorsal;  and  Klopsch  found  71 
lumbar  curves  in  121  cases.  Out  of  569  cases  in  the  Koyal  Orthopedic 
Hospital  of  lateral  curvature  470  cases  presented  curvature  with  convex- 
ity toward  the  right  side,  99  to  the  left  side.  Of  Adams'  and  Lonsdale's 
173  cases,  in  149  the  convexity  was  to  the  right  side,  and  in  24  the  con- 
vexity was  to  the  left  side. 

Some  discussion  has  taken  place  as  to  which  is  to  be  regarded  as  the 
primary  and  which  the  secondary  curve  in  cases  of  double  scoliosis. 
Bouvier,  Malgaigne,  and  most  French  writers  claim  that  the  dorsal  curva- 
ture toward  the  left  is  the  one  which  is  first  formed,  and  that  the  lumbar 
curve  is  generally  much  smaller,  with  the  concavity  to  the  right  and  sec- 
ondary (see  Malgaigne) ;  this  is  denied,  however,  by  many  surgeons, 
notably  Alexander  Shaw,  who  considers  that  the  lumbar  curve  is  the 
primary  one  and  that  the  dorsal  curve  is  secondary.  According  to  Schenk, 
the  lumbar  curve  is  the  most  common  primarily,  but  the  dorsal  curve  is 
most  commonly  brought  to  the  attention  of  physicians  on  account  of  the 
greater  deformity  due  to  a  torsion  of  the  ribs. 

Torsion.- — As  is  explained  under  the  head  of  pathology,  it  is  impossi- 
ble for  any  curvature  to  take  place  in  the  spinal  column  without  being 
accompanied  by  torsion  of  the  vertebrse  on  a  vertical  axis,  or  rotation  as 
it  is  frequently  termed. 

The  prominence  of  torsion  in  lateral  curvature  is  a  measure  of  the 
severity  of  the  case.  It  is  to  this  torsion  of  the  vertebrae  that  is  due  the 
necessary  alteration  of  the  position  of  the  ribs,  the  prominence  of  the 
shoulder  blade  as  Avell  as  the  flattening  of  the  chest  on  one  side,  the  dif- 
ference in  prominence  of  the  breasts  and  of  the  hips,  and  also  the  lumbar 
fulness. 

These  symptoms  of  torsion  may  be  present  before  any  curvature  can 
be  determined  in  the  line  of  the  spinous  processes,  the  projection  of  the 
shoulders,  or  of  the  hip,  constituting  the  first  evidence  of  lateral  curva- 
ture. 

Torsion  presents  the  most  characteristic  and  distressing  symptom  of 
lateral  curvature,  for  it  not  only  ca\ises  the  projection  of  the  shoulder 
and  the  hip — the  most  disfiguring  part  of  the  deformity — but  it  is  to 
torsion  and  its  consequences  that  the  greatest  contraction  of  the  chest 
and  resulting  disturbances  are  due. 


90 


ORTHOPEDIC   SURGERY. 


The  amount  of  torsion  may  be  much  greater  in  some  cases  than  would 
be  expected  by  the  slight  amount  of  apparent  lateral  deviation  of  the 
spinous  processes,  as  if  the  vertebrae  yielded  more  by  twisting  under 
superincumbent  weight  than  in  a  sideway  curve. 


Varieties  of  Lateral  Curvature. 

The  varieties  of  lateral  curvature  are  in  all  probability  not  so  numer- 
ous as  some  writers  would  lead  us  to  suppose,  but  as  there  are  many  dif- 
ferent   causes    which    may    produce 
the  distortion,  a  number  of  varieties 
may  be  readily  classified. 

A  lateral  deviation  is  sometimes 
seen  in  an  early  stage  of  caries  of 
the  spine,  and  at  the  later. stages  in 
untreated  or  neglected  cases  when 
the  consolidation  of  the  carious  bone 
has  taken  place  irregularly. 

The  distortion  may  follow  frac- 
ture or  dislocation,  and  is  occasion- 
ally seen  in  the  rare  affection,  spon- 
dylolisthesis, described  in  another 
chapter. 

In  sacro-iliac  disease  a  curvature 
of  the  spine  due  to  the  peculiarity 
of  the  attitude  is  quite  constant, 
and  in  torticollis  scoliosis  neces- 
sarily follows. 

Rhachitic  Lateral  Curvature. — 
This  form  occurs  in  rhachitic  chil- 
dren; but  it  is  not  so  common  a 
curve  as  the  antero-posterior  curve 
which  appears  as  a  backward  prom- 
inence in  the  lumbar  region  in  so  many  cases  of  rickets. 

The  pure  rhachitic  lateral  curvature  has,  according  to  Lorenz,  its 
greatest  curve  in  the  middle  of  the  spinal  column,  and  is  more  likely  to 
be  characterized  by  convexity  to  the  left. 

Guerin  claims  that  rhachitic  children  show  a  lateral  curvature  in  9.7 
.  per  cent  of  cases.  Eulenburg  found  that  in  rhachitic  scoliosis,  the  period 
of  development  of  the  curve  was  in  the  first  six  months  in  54  per  cent  of 
the  cases,  and  that  the  percentage  diminished  to  nothing  at  the  seventh 
year.  The  affection  is  as  common  in  boys  as  in  girls.  The  distortion 
may  or  may  not  be  accompanied  by  other  evidence  of  rickets,  but  in  most 
cases  the  other  signs  of  the  disease  are  marked. 


5.— Lateral  Curvature  Following 
Inequality  in  Length  of  Legs. 


Marked 


LATERAL   CURVATURE    OF    TIIK    ttl'JNE. 


91 


In  some  varieties  of  lateral  curvature  there  may  also  be  an  exagger- 
ated antero-posterior  curve  due  to  yielding  of  the  bones  under  tin;  un- 
usual distribution  of  superincumbent  weight. 

Static  Lateral  Curvature. — This  term  is  applied  to  that  form  due  to 
inequality  of  the  length  of  the  legs. 

A  slight  difference  in  the  length  of  the  lower  limbs  is  the  rule.  But 
development  of  lateral  curvature  directly  from  this  cause  is  not  invari- 


Fig.  97.— Lateral  Curvature  from  Infantile  Paralysis. 


Fig.  98.— Lateral  Curvature  from  Rickets. 


able,  as  is  evident  from  the  fact  that  in  a  comparatively  small  number  of 
cases  of  scoliosis  a  notable  difference  is  detected  in  the  length  of  the 
lower  limbs. 

Sklifosowsky  found  in  21  cases  of  lateral  curvature,  inequality  in  the 
length  of  the  limbs  in  IT.1     Staffel  found  in  230  cases  of  scoliosis  the 


'Centralbl.  f.  Chir.,  1884.  p.  43. 


92  ORTHOPEDIC    SURGERY. 

left  leg  shorter  in  62  cases.      H.  L.  Taylor  found  28  cases  of  shortening 
of  the  left  leg  in  32  cases  of  scoliosis. 

Furthermore,  from  only  a  comparatively  small  number  of  cases  of 
clearly  defined  shortened  limbs  from  infantile  paralysis,  hip  disease,  etc., 
does  true  scoliosis  result.  In  a  certain  number  of  cases,  however,  of 
shortened  limbs  from  these  affections,  a  marked  lateral  curvature  is  found, 
in  some  cases  characterized  by  rotation  of  the  ribs. 

That  curvature  should  develop  in  some  instances  and  not  in  others  is 
probably  due  to  the  fact  of  the  existence  in  certain  of  these  cases  of  less 
resistance  of  the  spinal  column  to  unfavorable  conditions. 

Paralytic  Lateral  Curvature.- — In  a  certain  number  of  cases  of  paraly- 
sis of  the  muscles  of  the  back  lateral  curvature  of  the  spine  is  found. 

When  the  muscles  of  the  back  are  weak,  the  patient  instinctively 
assumes  an  attitude  in  which  the  spine  is  balanced  with  the  least  action 
on  the  part  of  the  weakened  muscles.  The  bones  of  the  spine  may  be 
affected  (if  lacking  in  a  power  of  resistance)  by  a  constant  vicious  atti- 
tude, and  a  fixed  lateral  curvature  result. 

This  form  of  lateral  curvature  is  most  commonly  developed  after  in- 
fantile paralysis,  as  this  is  the  most  common  form  of  paralysis  occurring 
in  the  growing  years;  but  the  effect  of  other  palsies,  if  influential  in 
weakening  certain  muscles  of  the  back,  would  be  the  same,  and  the  dis- 
tortion may  be  seen  after  spastic  paralysis,  progressive  muscular  hyper- 
trophy, syringomyelia,  and  other  affections  weakening  the  muscles  of  the 
spinal  column. 

Lateral  Curvature  from  Contracture  of  the  Chest. — Lateral  curvature 
may  follow  empyema  and  some  deviation  of  the  spinal  column  almost 
necessarily  follows  severe  forms  of  empyema.  In  the  purest  forms  of 
this  type  there  is  no  true  scoliosis,  the  spine  not  being  twisted  to  a 
noticeable  extent,  but  simply  pulled  to  one  side,  the  ribs  being  flattened, 
i.e.,  fixed  obliquely  at  a  lower  angle  than  normal,  from  the  cicatricial 
contraction  of  the  lung  which  prevents  expansion  of  the  lung  on  that  side 
and  leads  to  an  increased  expansion  on  the  other.  In  certain  cases,  how- 
ever, the  altered  position  so  induced  has  its  effect  upon  the  growth  of 
the  spine,  and  a  true  lateral  curvature  with  torsion  takes  place. 

It  has  been  said  that  a  curvature  followed  in  some  instances  pneu- 
monia and  phthisis,  but  this  is  not,  according  to  Mr.  Adams,  commonly 
the  case. 

Lateral  curvature  in  a  case  of  sarcoma  of  the  ribs  and  lung  has  been 
reported  by  Shattuck. ' 

Lateral  Curvature  from  Occupation. — Lateral  curvatures  of  severe 
type  due  to  occupation  are  not,  as  a  rule,  so  common  as  other  forms,  for 
the  reason  that  laborious  occupations  are  not,  in  general,  entered  upon 


1  Boston  Med.  and  Surgical  Journal,  January  10th,  1880. 


LATERAL   CURVATURE    OF   THE    SPINK. 


93 


until  an  age  when  the  spinal  column  has  a  sufficient  amount  of  resistance 
to  withstand  the  superimposed  weight. 

Slight  lateral  curves  may  be  seen,  similar  to  the  kyphosis  of  those 
employed  in  occupations  requiring  stooping.  Scoliosis  in  school  children 
is,  in  fact,  a  curvature  from  occupation  in  a  true  sense,  though  the  term 
as  ordinarily  used  is  not  so  applied.  In  clerks  one  shoulder  is  often 
higher  than  the  other  from  the  attitude  of  writing,  and  it  is  said  to  he 
true  also  in  blacksmiths.     Severe  forms  of  this  class  are  sometimes  seen 

in  adolescents  whose  occu- 
pation habitually  twists  the 
spine,  as  in  carrying  bas- 
kets or  trays.  Arbuthnot 
Lane  has  called  special  at- 


Fig.  99.— Lateral  Curvature  Following  Empyema. 


Fig.  100.— Lateral  Curvature  in  Sacro- 
iliac Disease. 


tention  to  this  fact,  and  has  also  observed  that  the  shape  of  the  lateral 
curve  varied  in  a  measure  with  the  occupation. 

In  short,  occupations  which  require  constant  one-sided  attitudes,  as  in 
the  clerk,  artist,  blacksmith,  etc.,  may,  in  certain  individuals,  develop  a 
lateral  deviation  of  the  spinal  column  as  the  natural  result  of  this  con- 
stant position. 

Scoliosis  in  nursing  women,  from  carrying  infants  too  frequently 
upon  one  side,  is  also  recorded,  and  the  same  attitude  in  one-armed  per- 
sons. Lateral  curvature  from  a  peculiar  position  in  sitting  has  also  been 
noted  due  to  inequality  of  eyesight. 


1)4  ORTHOPEDIC   SURGERY. 

Ischias  scoliotica,1  referred  to  also  as  scoliosis  neuromuscular  is,  or 
neuropathica  or  ischiatica,  is  a  term  which  has  been  applied  to  lateral 
curvature  in  the  lower  part  of  the  spinal  column  occurring  in  connection 
with  sciatica.  It  is  severest  in  cases  in  which  the  lumbar  nerves  are  in- 
volved. The  curvature  may  be  to  the  side  of  the  affected  nerve,  or  the 
reverse,  or  it  may  alternate.  The  condition  is  most  easily  relieved  by 
fixative  appliances. 

Physiological  Curve. — What  has  been  termed  a  physiological  curva- 
ture has  been  described  by  Bouvier.  Such  a  curve  is  usually  found  with 
the  convexity  to  the  right  in  the  dorsal  region ;  it  is  sometimes  seen  at 
autopsy,  but  not  in  young  children.  It  is  supposed  to  be  due  to  the 
weight  of  the  heart,  or  to  the  greater  use  of  the  right  arm  or  right  side 
of  the  body.  The  importance  of  this  curve  is  not  so  great  "as  is  supposed 
by  some  writers.  In  fact  the  existence  of  this  physiological  curve  has 
been  denied  by  many  authorities. 

Flexible,  Fixed,  and  Structural  Ciirves. — Varieties  have  been  made 
by  some  writers  who  wish  to  classify  lateral  curvatures  as  flexible  or  fixed 
according  to  their  disappearance  or  persistence  on  a  change  of  attitude. 
Structural  curves  are  described  as  those  in  which  a  change  in  the  struc- 
ture and  shape  of  the  bones  has  taken  place. 


Etiology. 

A  great  deal  haS  been  written  on  the  subject  of  the  causation  of  lateral 
curvature,  and  the  question  is  still  a  vexed  one,  although  at  present  the 
weight  of  authority  favors  the  opinion  that  the  deformity  is  chiefly 
brought  about  by  mechanical  influences. 

The  theories  advanced  to  explain  the  phenomena  of  lateral  curvature 
are  the  following: 

1.  That  the  distortion  is  due  to  unequal  muscular  action,  as  is  true 
in  torticollis.  2.  That  the  cause  is  to  be  found  in  an  inequality  of 
growth  of  different  portions  of  the  vertebrae,  as  if  the  affection  were  to 
be  classed  as  a  localized  unilateral  hypertrophy.  3.  That  the  distortion 
is  the  result  of  superincumbent  weight  acting  upon  a  faulty  condition  of 
the  spinal  column. 

One  of  the  most  notable  causes  alleged  for  those  cases  in  the  first 
group  is  that  of  active  muscular  contraction,  which  was  advocated  by 
Jules   Guerin,  who  believed  that  lateral  curvature  was  caused  by  the 

1  Gussenbauer :  Prag.  med.  Wochenschr.,  1890;  Albert:  Wien.  med.  Presse, 
1886,  Nos.  1  and  3  ;  Nicoladoni  :  Wien.  med.  Presse,  1886,  Nos.  26  and  27  ;  Schudel : 
Arch.  f.  klin.  Chir.,  1889,  xxxviii.  ;  Remak :  Deutsche  med.  Wochensch.,  1891,  No. 
7;  Vulpius :  Deutsche  med.  Wochenschr.,  September,  1895;  Topp :  Zeitschr.  f. 
■Orth.  <Ohir.,  1899,  vi.,435;  "Ischias  Scoliotica,"  Langenbeck1s  Archiv,  1889. 


LATERAL   CURVATURE   OF   THE   SPINE.  95 

spasmodic  contraction  of  certain  muscles,  in  the  same  way  that  the  head 
is  twisted  in  torticollis.  As  a  result  of  this  belief,  myotomy  of  muscles 
on  the  concave  side  of  the  curve  was  recommended  by  Guerin,  and  in  one 
case  he  performed  thirty  or  forty  muscular  divisions.  Both  this  method 
and  theory  have  fallen  into  discredit.  The  facts,  as  seen  clinically,  do 
not  substantiate  such  a  theory.  In  the  cases  of  true  lateral  curvature  at 
an  early  stage,  not  only  is  there  no  spasm,  but  no  contraction  even  of  the 
muscles  on  the  concave  side  of  the  curve;  and  the  contraction  seen  in  the 
later  stages  of  pronounced  curves  can  be  explained  by  the  supposition  of 
the  adaptive  shortening  of  the  muscles. 

It  may  be  assumed  that  although  in  exceptional  cases  there  may 
exist  an  active  contraction  of  certain  muscles  as  a  cause  for  lateral  curva- 
ture (as  is  the  case  in  torticollis  and  in  some  instances  of  caries  of  the 
ilium  or  lumbar  vertebrae),  yet  these  cases  are  so  exceptional  as  to  be 
insufficient  to  establish  a  rule  for  the  treatment  of  scoliosis.  Stromeyer 
and  Barwell  have  spoken  of  the  contraction  of  the  serratus  muscle  as  a 
cause  of  this  deformity.  This,  however,  has  hot  found  general  accept- 
ance. 

A  much  more  probable  presentation  of  the  muscular  theory  is  that 
which  has  received  the  able  advocacy  of  Eulenburg  and  which  has  met 
with  acceptance  from  many  authorities  and  been  the  foundation  of  a 
system  of  treatment.  The  theory  may  be  stated  as  follows :  Continuous 
muscular  action  is  necessary  "for  holding  the  trunk  erect.  If  all  the  mus- 
cles are  not  in  continuous  action  they  must  be  constantly  on  guard  to  pre- 
vent any  deviation  from  the  normal  position.  If  any  of  the  muscles  are 
weakened,  the  spinal  column  will  tend  to  bend,  the  deviation  falling  with 
the  convexity  on  the  side  of  the  weakened  muscles — the  side  of  the  con- 
cavity being  that  of  the  normal  muscles.  In  weak  individuals,  habits  of 
attitude,  continued  for  a  long  time,  will  weaken  certain  muscles  by  over- 
stretching them,  and  will  cause  distortion  to  ensue. 

The  objection  to  this  theory  is  that  it  cannot  satisfactorily  explain  all 
the  facts.  Diminution  in  the  strength  of  the  muscles  has  in  the  early 
cases  not  always  been  evident,  and  such  as  has  been  found  is  in  the 
severe  cases  only  what  would  result  from  the  long-continued  disuse 
of  the  muscles.  Furthermore,  lateral  curvature  is  often  developed  in 
individuals  of  apparently  strong  muscles.  There  is,  moreover,  no  proof 
that  muscles  are  weakened  by  the  slight  over-stretching  which  follows  the 
habits  of  standing  or  sitting  seen  in  children.  As  Lorenz  has  justly  ob- 
served, the  habits  of  sitting  or  standing  on  one  leg  should,  if  Eulen- 
burg's  theory  is  correct,  develop  an  abnormal  attitude  of  the  hip,  knee, 
or  elbow,  from  muscular  action. 

Eulenburg' s  theory  can,  however,  not  be  readily  dismissed.  Even  if 
the  purely  mechanical  theory  of  lateral  curvature  due  to  static  influences 
be  accepted,  it  is  presumable  that  the  faulty  attitudes  frequently  assumed 


96  ORTHOPEDIC   SURGERY. 

by  children  in  sitting  and  standing  may  be  due  to  a  lack  of  strength  of 
certain  groups  of  muscles,  either  inherited  or  acquired  by  accident;  al- 
though it  is  not  possible  to  demonstrate  such  impaired  muscular  strength 
of  these  muscles.  In  other  words,  muscular  weakness  may  be  regarded 
as  a  predisposing  influence,  if  not  an  actual  cause  of  the  deformity. 

With  this  in  view  it  is  alleged  that  the  distortion  is  probably  due 
to  disturbed  muscular  conditions  involving  impaired  muscular  power  on 
one  side.  The  muscles  primarily  affected  are  probably  not  the  external 
muscles  moving  the  spinal  column,  but  the  internal  group  which  pass 
from  vertebra  to  vertebra,  and  act  on  the  column  in  segments. 

The  second  theory,  that  of  abnormal  growth,  is  advocated  by  Hueter 
and  Engell,  who  believe  that  in  some  cases  there  is  an  abnormal  growth 
of  one  side  of  the  thorax,  including  the  ribs  and  the  vertebrae,  similar  to 
the  unilateral  atrophy  or  hypertrophy  seen  elsewhere ;  and  that  there  is 
an  abnormal  ossification  at  the  ends  of  the  ribs  in  early  childhood  from 
which  cause  the  thorax  is  twisted  and  developed  asymmetrically. 

Delpech  and  Bouvier  think  that  faulty  attitudes,  instead  of  being  the 
cause,  are  the  result  of  lateral  deviation,  which  are  themselves  due  to 
asymmetrical  development  of  the  bodies  of  the  vertebrae. 

The  position  of  the  heart  on  the  left  side  of  the  body  has  been  ex- 
plained to  be  an  exciting  cause  for  lateral  curvature  with  the  convexity 
toward  the  right.  This,  however,  cannot  be  construed  as  true.  The  use 
of  the  right  arm  cannot  be  held  wholly  accountable,  for  in  left-handed 
persons  the  left  shoulder  is  frequently  found  higher  than  the  right. 

Many  objections  can  be  urged  against  this  theory;  but  the  most  im- 
portant is,  that  it  does  not  correspond  with  clinical  facts. 

Lorinser  has  advanced  a  theory  of  subacute  inflammatory  changes  in 
the  structure  of  the  bone,  but  there  is  little  to  be  said  in  support  of  such 
a  view.  Lesser  urged  the  view  that  the  unequal  action  of  the  different 
halves  of  the  diaphragm  through  unilateral  paralysis  of  the  phrenic 
nerves  gave  rise  to  the  deformity. 

The  doctrine  of  faulty  innervation  as  a  cause  of  scoliosis  has  been 
advanced,  but  it  has  not  yet  received  any  acceptance. 

The  third  theory  is  that  of  superincumbent  weight.  The  majority  of 
authorities  favor  this  theory,  urged  by  Koser  and  Volkmann,  who  con- 
sider the  deformity  as  the  result  of  the  gradual  mechanical  force  of  the 
superincumbent  weight  falling  upon  the  spinal  column  which  is  not  held 
erect,  and  which  is  incapable  of  resisting  the  pressure  which  falls  upon  it. 

The  facts  connected  with  lateral  curvature  may  be  briefly  stated  as 
follows : 

The  distortion  occurs  chiefly  in  childhood  and  develops  fully  in  adoles- 
cence. In  the  earliest  types  there  is  an  habitual  distorted  attitude  which 
can  be  corrected  by  removing  the  superincumbent  weight;  in  the  later 
forms  the   distortion  can  be  only  slightly  overcome  by  removing    this 


LATERAL   CURVATURE    OF   THE    SPINE.  97 

weight,  and  in  the  most  severe  forms  no  change  can  be  effected,  in  this 
way. 

It  remains,  therefore,  to  investigate  whether  the  anatomical  changes 
found  in  cases  of  the  severer  type  are  such  as  can  be  caused  by  superin- 
cumbent weight.  As  has  already  been  stated,  these  changes  are  chiefly 
a  twist  ot  the  spinal  column,  and  such  alterations  of  the  different  vertebra; 
as  would  follow  such  a  twist,  provided  the  bony  structures  were  unable 
to  sustain  such  a  downward  pressure.  To  demonstrate  that  superincum- 
bent weight  could  cause  the  twist  the  following  experiments  were  tried : 
Observation  I. '  The  spinal  column  of  a  full-term  infant  was  removed, 
leaving  the  skin,  superimposed  muscles,  and  ligaments  intact,  but  remov- 
ing the  ribs.  It  was  found  that  although  the  column  was  more  flexible 
than  in  children,  adolescents,  or  adults,  rotation  was  not  readily  brought 
about  by  simply  pressing  the  two  ends  toward  each  other,  holding  each 
end  in  the  hand;  the  amount  of  lateral  deviation,  that  is,  curving  side- 
ways, without  rotation  of  the  bodies  was  not  great,  though  much  greater 
than  in  well-grown  spinal  columns.  The  most  noticeable  effect  of  press- 
ing the  upper  part  downward  was  to  cause  a  bending  with  the  concavity 
forward;  bending  with  the  concavity  backward  was  possible  only  to  a 
comparatively  slight  degree.  Rotation  was  easily  produced  by  twisting 
the  spine. 

Observation  II.  The  body  of  a  young  female  adult  was  hung  by  the 
head  with  the  head  fixed  and  the  body  free  from  the 'floor;  the  skin  of 
the  back  having  been  dissected  off,  long  pins  were  driven  in  the  occiput 
and  in  the  spinous  processes  of  the  different  vertebrae ;  a  thread  with  a 
weight  was  hung  from  the  pin  in  the  occiput,  long  enough  to  touch  the 
floor,  and  a  second  thread  with  a  piece  of  chalk  attached  was  hung  suc- 
cessively from  the  pins  inserted  in  the  different  spines  and  from  the 
sacrum.  The  pelvis  was  then  twisted  forcibly  and  the  arc  marked  off  on 
the  floor  by  the  piece  of  chalk,  as  suspended  from  the  different  pins,  was 
measured  from  that  point  in  the  circle  indicated  by  the  plumb  line,  hung 
from  the  pin  inserted  in  the  immovable  head. 

The  figures  are  as  follows,  measured  from  the  line  from  the  occiput : 

Arc  described  by  a  line  from  sacrum,  150° 

"         "          "          "         axis,  60° 

first  dorsal,  83° 

"          "          "          "          third  dorsal,  100° 

"          "          "          "          sixth  dorsal,  118° 

"          "          "          "          twelfth  dorsal,  130° 

third  lumbar,  136° 

While  these  figures  are  only  approximate,  as  the  amount  of  force  used 

'The  writers  are  indebted  to  Professor Dwight  and  Drs.  Mixter,  Conant,  Newell, 
and  Burrell  of  the  Harvard  Medical  School  for  their  assistance  in  their  experiments. 

7 


98  ORTHOPEDIC   SURGERY. 

in  the  successive  twistings  was  not  measured  and  presumably  not  the 
same,  yet  they  indicate  that  the  amount  of  rotation  possible  is  greatest  in 
the  dorsal  region,  leaving  out  of  account  the  twisting  possible  in  the  atlo- 
axoid  articulation.  The  three  or  four  upper  dorsal  vertebrae  moved  to- 
gether; the  greatest  rotation  appeared  to  be  in  the  third  lower  dorsal; 
lateral  deviation  (that  is,  without  rotation)  was  possible  only  in  the 
lower  dorsal  vertebras.  Pressure  made  on  the  floating  ribs  appeared 
to  have  little  effect  in  twisting  the  vertebrae,  but  pressure  on  the 
thoracic  ribs  appeared  in  a  measure  to  affect  the  line  of  the  spinal 
column.  Some  play  in  the  costo-vertebral  articulation  existed,  but 
beyond  that  point  pressure  exerted  on  the  ribs  was  transmitted  to  the 
column. 

Volkmann1  found  that  in  life  the  greatest  possible  twist  of  the  whole 
body,  including  that  occurring  in  the  hip-joints,  was  144°,  so  that  the 
figures  here  given  are  overstatements  of  the  possible  physiological  limits 
of  rotation.  This  is  also  somewhat  greater  than  that  indicated  by  the 
facets  of  the  disarticulated  vertebras,  which  would  show  that  if  the  joints 
were  firm  there  would  be  absolutely  no  rotation  in  the  lumbar  region, 
little  in  the  cervical,  except  in  the  atlo-axoid  articulation,  and  not  much 
in  the  dorsal  region.  A  certain  amount  of  laxity  in  the  articulation 
allows  more  play  than  would  be  supposed  by  the  structure  of  the  bones. 
This  was  evident  on  forcibly  twisting  the  cadaver. 

The  amount  of  forward  and  backward  motion  possible  in  an  adult  is 
much  less  than  would  be  supposed.  This  is  apparent  on  inspection,  and 
has  been  accurately  measured  by  Meyer.2 

Observation  III.  The  whole  spinal  column  of  an  adult  male,  a  dis- 
secting-room subject,  was  taken,  including  a  portion  of  the  pelvis,  and 
the  base  of  the  cranium.  The  larger  muscles  were  removed,  but  the 
ligaments  and  smaller  muscles  were  kept.  The  pelvis  was  firmly  held  in 
a  vise  and  a  box  was  secured  on  the  cranium  by  passing  a  rod,  firmly 
secured  to  the  box  down  into  the  medullary  canal  of  the  cervical  verte- 
brae; the  box  was  then  secured  so  that  it  would  move  up  and  down,  but 
not  laterally ;  weights  were  placed  in  the  box. 

It  was  found  that  the  spinal  column  could  bear  a  considerable  weight 
without  yielding  to  any  noticeable  extent.  As  the  amount  was  increased 
a  curvature  with  concavity  forward  was  seen,  which  increased  as  the 
weight  was  increased  up  to  eighty-four  pounds.  No  rotation  of  the 
vertebrae  was  observed  so  long  as  the  weight  bore  down  directly,  but 
rotation  of  the  lower  dorsal  and  lumbar  region  was  seen  when  any  lateral 
deviation  was  made  in  the  cervical  region;    the  amount  of  rotation  or 

1  Virchow's  Archiv,  1872. 

2 "Die  Statik  und  Mechanik  des  menschlichen  Knochengerilstes,"  p.  210;  Vir- 
chow's Archiv,  Bd.  xxxv.,  p.  225;  Ibid.,  Bd.  xxxvi.,  1866,  p.  144;  Ibid.,  xxxviii., 
p.  15. 


LATERAL   CURVATURE    OF   THE   SPINE. 


99 


deviation  was,  however,  very  small  as  compared  with  that  possible  in 
children. 

None  of  these  experiments  approximately  reproduced  the  conditions 
to  be  found  in  life,  as  the  attachments  of  the  ribs  had  been  severed  and 
the  viscera  removed.  Furthermore,  the  spinal  column  in  the  adult  is 
much  less  flexible  than  that  of  a  child  or  adolescent,  in  whom  lateral 
curvature  is  usually  observed. 

Observation  IV.  The  body  of  an  infant  of  a  year  was  prepared  in 
the  following  way:    The  thighs  were  amputated  near  the  hip-joints  and 


Fig.  101.— Experiment  to  Demonstrate  Causation  of  Lateral  Curvature. 

the  pelvis  was  fixed  upon  the  remaining  stumps  and  secured  by  means  of 
nails  on  a  board,  long  pins  were  passed  laterally  through  the  pelvis  and 
secured  to  the  board  by  means  of  hooks,  and  the  whole  pelvis  was  then 
embedded  in  plaster- of -Paris. 

The  board  to  which  the  body  was  secured  was  then  placed  on  a  stand 
with  four  upright  rods  attached  at  the  four  corners,  to  which  rods  a  flat 
board  was  attached  so  that  it  would  slide  smoothly  up  and  down.  The 
child's  trunk  therefore  was  placed  between  two  boards,  one  being  fixed 
and  the  other  pressing  down  upon  the  child's  head.     To  keep  the  head  in 


100  ORTHOPEDIC   SURGERY. 

place  it  was  inserted  in  a  tightly  fitting  tin  cylinder  which  was  fastened 
to  the  under  surface  of  the  board.  Weight  placed  upon  the  upper  board 
(sliding  as  it  did  freely  upon  the  uprights)  brought  a  downward  pressure 
upon  the  child's  head  and  shoulders.  To  make  the  latter  more  even,  a 
wooden  collar  was  placed  around  the  neck  resting  on  the  shoulders. 
Long  pins  were  then  inserted  in  the  spinous  processes  of  the  vertebra1  so 
that  rotation  could  be  more  readily  noticed.  To  check  the  falling  for- 
ward of  the  neck,  a  cord  was  placed  around  the  neck  and  fastened  at  the 
side  to  the  uprights,  acting  as  a  check,  just  as  in  life  the  longer  muscles 
of  the  back  would  act  in  keeping  the  body  erect. 

Downward  pressure  upon  the  upper  board  caused  the  child's  back  to 
bend  backward  (convexity  backward).  When  carried  beyond  a  certain 
point  the  column  would  bend  sideways  with  marked  rotation,  with  the 
changes  usually  noticed  in  the  ribs,  flattening  on  the  side  of  the  concavity 
and  projection  on  the  side  of  the  convexity.  This  projection  was  most 
marked  in  the  middle  and  upper  dorsal  region,  but  the  amount  of  greatest 
rotation  appeared  to  be  in  the  lower  dorsal  region.  If  the  angle  of  down- 
ward pressure  was  changed,  or  if  the  pelvis  was  tipped  so  as  to  cause  a 
curve  in  the  spinal  column,  the  effect  of  downward  pressure  was  more 
marked. 

Rotation  of  the  vertebras  was,  of  course,  readily  produced  by  lateral 
pressure  twisting  the  spine ;  and  on  removing  all  downward  pressure,  by 
placing  the  cadaver  in  a  horizontal  position  rotation  and  curvature  in  the 
dorsal  region  was  easily  made  by  twisting  the  pelvis  and  holding  the  head 
fixed,  or  vice  versa,  the  axis  of  the  head  and  pelvis  being  kept  the  same. 

Although  a  well-marked  scoliosis  was  thus  artificially  produced,  at- 
tended by  the  characteristic  flattening  of  the  ribs  on  the  side  of  the 
concavity  and  projection  on  that  of  the  convexity,  yet  a  more  careful 
examination  appeared  to  show  that  although  this  was  the  result  of  down- 
ward pressure,  it  was  downward  pressure  not  exerted  in  a  perfectly  verti- 
cal direction;  for  although  the  force  was  applied  properly,  yet  it  was 
not  possible  to  prevent  some  play  in  the  cervical  region,  from  which  it 
resulted  that  the  force  fell  obliquely  upon  the  under  portion,  of  the 
spinal  column,  causing  curvature  and  necessarily  rotation. 

The  accompanying  illustration  (drawn  from  a  photograph)  indicates 
the  lateral  curvature  produced  in  the  experiment. 

The  photograph  of  a  case  of  lateral  curvature  in  a  grown  child  shows 
the  similarity  of  the  shape  of  the  back  m  true  lateral  curvature  to  that 
of  the  experiment. 

If  it  were  practicable  to  apply  a  force  directly  downward  and  trans- 
mit it  through  the  cervical  and  upper  dorsal  region  without  deviation, 
the  effect  upon  the  lower  dorsal  region  would  be  to  cause 'an  antero- 
posterior curvature. 

The  lateral  curvature  therefore  results  from  downward  pressure,  but 


LATERAL   CURVATURE    OF   THE    SPINE.  101 

downward  pressure  applied  obliquely  upon  some  portion  of  the  spina.! 
column.  Rotation  follows  from  the  anatomical  structure  of  the  inter- 
locked vertebrae,  it  being  possible  for  them  to  rotate  slightly,  while  the 
amount  of  tipping  sideways  (without  twisting;  which  the  articular  facets 
permit  is  much  less. 

Rotation  takes  place  with  the  vertebral  bodies  directed  toward  the 
convexity  and  the  spine  to  the  concavity  for  the  reason  that  the  former, 
being  larger,  are  unable  to  be  crowded  into  the  smaller  space  of  the  con- 
cavity, and  are  pushed  in  the  direction  where  there  is  more  space.  The 
fact  also  has  been  pointed  out  by  Judson,  that  the  bodies  are  free  while 
the  spines  are  held  by  muscles  which  may  give  the  former  more  freedom 
in  movement. 

From  the  above  facts  the  following  generalizations  may  be  made: 

The  effect  of  the  weight  of  the  thorax,  head,  and  shoulders  would 
be,  if  applied  in  a  vertical  direction,  to  bend  the  spinal  column  forward 
and  backward,  but  in  flexible  spines  the  superincumbent  weight  rarely 
falls  directly,  and  curvature  follows.  This  is  at  first  a  physiological 
process,  but  it  subsequently  becomes,  by  the  alteration  in  the  shapes  of 
the  bones  under  altered  pressure,  a  pathological  change. 

•  The  extent  of  the  curvature  and  the  situation  of  the  curve  will  be 
determined  by  the  attitude  habitually  taken  by  the  individual,  and  per- 
haps also  by  a  difference  in  the  resisting  power  in  different  parts  of  the 
column. 

The  injurious  effect  of  superincumbent  weight  in  curving  the  spine 
is  increased  by  the  obliquity  of  the  pelvis,  or  the  inclination  of  the  shoul- 
ders so  frequently  taken  by  persons  of  weak  muscular  systems  in  sit- 
ting sideways  and  leaning.  The  curve  is  usually  in  the  dorsal  region, 
with  the  right  shoulder  raised,  as  the  majority  of  people  are  right- 
handed. 

The  distortion  is  one  of  growing  years,  and  is  more  common  in  girls 
than  boys,  for  two  reasons,  namely,  that  at  the  age  when  lateral  curva- 
ture is  usually  seen  first  girls  grow  more  rapidly  than  boys,  and  their 
muscular  system  is  less  well  developed  from  the  customary  life  habits  of 
girls  in  society.  The  effect  of  superincumbent  weight  upon  a  yielding 
spine  in  adult  life,  after  the  vertebra?  have  ceased  to  grow,  is  to  cause  an 
increase  in  the  antero-posterior  curve  of  the  back. 

The  lack  of  normal  resistance  of  the  bony  structures  of  the  spinal 
column,  in  part  or  in  whole,  may  be  supposed  to  exist  in  certain  individ- 
uals without  the  supposition  of  any  pathological  change  of  sufficient  grav- 
ity to  be  classed  as  rickets.  During  the  age  of  growth,  complete  ossifica- 
tion of  the  different  vertebra?  has  not  been  attained.  It  is  well  known  in 
certain  cases  that  in  rapidly  growing  persons  the  ossification  of  the 
spine  does  not  make  equal  progress  with  the  ossification  elsewhere. 

Alexander    Shaw    mentions    two    preparations    of   the    spine    in   the 


102  ORTHOPEDIC   SURGERY. 

Museum  of  the  Middlesex  Hospital,  where  such  a  condition  of  things 
existed. ] 

Analogous  to  this  condition  is  that  found  in  the  knock-knee  develop- 
ing about  the  time  of  puberty.  This  view  would  be  supported  by  Vogt, 
who  calls  attention  to  the  fact  that  the  development  of  ordinary  lateral 
curvature  comes  at  periods  of  the  physiological  increase  of  the  process  of 
ossification  of  the  whole  skeleton.  Vogt  describes  three  periods  of  in- 
crease of  growth:  1st,  includes  the  first  two  years;  2d,  the  beginning  of 
the  second  dentition  in  the  seventh  year  to  the  approach  of  the  time  of 
puberty ;  3d,  the  period  of  puberty.  Fisher  writes  that  attention  should 
be  especially  directed  to  the  fact  that  mere  constant  bending  of  the  spine 
to  one  side  will  not  induce  a  structural  change;  that  there  must  exist 
also  within  the  column  itself  some  contributory  defect,  without  which 
lateral  curvature  will  not  become  developed. 

Adams  and  Fisher  believe  that  this  contributory  defect  is  in  the  struc- 
tural relaxation  or  weakness  of  the  ligaments,  rather  than  in  a  lack  of 
resistance  of  the  bones.  Fisher,  however,  himself  compares  the  condi- 
tion to  that  seen  in  knock-knee,  which  is  now  generally  regarded  to  be 
due  to  an  osseous  rather  than  to  a  ligamentous  defect. 

The  constitutional  influence  in  the  development  of  lateral  curvature 
is  little  understood.  Drachmann  found  that  only  a  small  portion  of  the 
anaemic  and  scrofulous  children  in  the  28,000  scholars  examined  were 
scoliotic.  An  hereditary  predisposition  to  spinal  curvature  frequently 
coexisting  with  a  consumptive  tendency  is  mentioned  by  Adams  as  oc- 
curring in  girls  from  seven  to  twelve  years  of  age  or  later ;  and  in  those 
cases  the  curvature  tends  to  increase  rapidly  and  terminate  in  a  conspicu- 
ous deformity;  but  lateral  curvature  of  the  spine  according  to  Adams 
rarely  coexists  with  consumption.  Eulenburg  found  that  25  per  cent  of 
scoliotic  patients  showed  some  hereditary  tendency  toward  the  affection. 
Vogt  found  it  in  one-half  of  his  cases.  While  Eupprecht2  considers 
ordinary  lateral  curvature  as  rhachitic,  Lorenz  thinks  that  weakly  chil- 
dren have  ipso  facto  a  disposition  to  lateral  curvature;  but  he  is  unwilling 
to  say  that  in  cases  in  which  it  occurs  the  children  are  always  rhachitic ; 
for  the  lack  of  resistance  of  a  rapidly  growing  bone  may  be  sufficient, 
under  certain  static  conditions,  to  develop  the  lateral  distortion. 

Sigfried  Levy3  thinks  that  there  are  two  distinct  etiological  factors 
in  the  production  of  habitual  scoliosis:  one,  "an  anomaly  of  nutrition, " 
a  purely  organic  matter;  secondly,  certain  mechanical  causes — faulty 
positions  of  standing  and  sitting.  Neither  one  of  the  factors  can  cause 
it  alone ;    both  must  be  present  at  the  same  time.     In  support  of  this 


1  Holmes'  "System  of  Surgery,"  vol.  iii.,  American  edition. 

2  Vide  Centralbl.  f.  orthop.  Chir.,  1886,  2. 
3AlsoBusch:  Berl.  klin.  Wochenschrift,  1880,  p.  106,  vol.  i. 


LATERAL   CURVATURE    OF   THK    SPINE. 


L03 


view,  he  speaks  of  a  case  which  lie  saw,  in  which  a  girl  of  three  years  had 
a  resection  of  the  knee,  and  grew  up  with  one  leg  9  cm.  shorter  than  the 
other.  The  pelvis  was  always  tilted,  but  there  was  no  suspicion  of  sco- 
liosis until  she  was  twelve  years  old,  when  she  •**#&& 
began  to  have  headache,  pain  in  the  side,  mal- 
aise, etc.,  and  in  spite  of  all  precautions  a  ^wlvif 
typical  lateral  curvature  rapidly  developed.     He 


FIG.  102. 


Fig.  104. 


FIG.  103.  FIG.  105. 

Figs.  103-105— Incorrect  Attitudes  of  Sitting  in  Scnooi  Children.    (Scudder.) 


104 


ORTHOPEDIC    SURGERY. 


has  seen  three  other  such  cases ;  and  in  over  a  hundred  cases  of  habitual 
scoliosis  which  he  has  observed,  in  every  case  symptoms  of  general  dis- 
turbance (as  in  the  case  related  above)  accompanied  the  development  of 
the  deformity. 

As  has  been  shown  by  ltedard,  the  position  in  which  children  in  artns 
are  carried,  if  persisted  in  for  many  hours,  may  develop  abnormality  in 
the  shape  of  certain  of  the  vertebrae.  This  remains  unnoticed  in  early 
youth,  but  as  the  weight  of  the  trunk  increases,  gives  to  a  weak-muscled 
child  greater  ease  in  a  one-sided  position,  and  the  position  becomes  ha- 
bitual and,  under  the  proper  conditions,  scoliosis  follows. 

Symmetrical  development  on  both  sides  in  the  shape  of  the  vertebral 
bodies  is  not  the  rule,  as  was  shown  by  Dr.  R.  Tun  stall  Taylor  in  an 
examination  of  a  number  of  normal  adult  spines  in  the  Warren  Museum, 
at  the  Harvard  Medical  School. 

As  is  well  stated  by  Fisher,  the  causes  of  lateral  curvature  are  the 
predisposing  and  the  proximate. 

1.  Predisposing  causes,  which,  are  constitutional,  such  as  debility, 
rickets,  or  a  condition  of  lack  of  resistance  in  certain  of  the  vertebrae. 

2.  Proximate  causes  (essentially  local),  which  disturb  the  equilibrium. 
These  are  vicious  positions,  sitting  positions,  faulty  attitudes,  empyema, 
or  any  long-continued  irregular  distribution  of  weight.     To  this  can  be 

added  an  inequality  in  the  length  of  the  limbs, 
which  is  an  occasional  predisposing  cause. 

Pathology. 

The  pathological  changes  in  true  lateral 
curvature  are  not  those  resulting  from  any 
destructive  disease  of  the  vertebrae,  but  simply 
the  alterations  of  bone  altered  under  pressure 
in  an  abnormal  direction. 

The  changes  are  chiefly  to  be  noticed  in  the 
spinal  column,  viz.,  the  bodies  of  the  verte- 
brae, the  articulating  processes,  and  the  spines ; 
but  in  severe  cases  all  the  bones  of  the  trunk 
may  be  altered  and  also  the  pelvis.  The  mus- 
cles and  ligaments  are  altered  in  their  tonicity 
and  length,  and  internal  organs  may  be  dis- 
placed. 

The  changes  seen  necessarily  vary  accord- 
ing to  the  stage  of  the  affection  and  the  de- 
gree to  which  the  deformity  has  developed,    and   consist  chiefly   of   a 
curvature  and  torsion. 

In  the  flexible  stage  of  scoliosis  no  anatomical  change  will  be  found  in 


Fig.  106.— Distortion   of  Ribs  in 
Lateral  Curvature.    (Schreiber.) 


LATERAL   CURVATURE    OF   TIIK    SPINE. 


10f> 


Via.  107.— Ktaachitic  Lateral  Curvature  of  Spine,  from  Specimen  in  the  Warren  Museum. 


106 


ORTHOPEDIC   SURGERY. 


the  bones,  ligaments,  or  muscles;  but  in  the  stage  of  fixed  curves,  and  in 
the  latest  phases  of  the  affection,  marked  distortion  of  the  vertebral 
bodies  is  to  be  observed. 

Wherever  a  side  curve  of  the  spine  has  taken  place  the  bodies  are 
crowded  together  on  the  concave  and  separated  on  the  convex  side  of  the 
curve.  Growing  bone  adapts  itself  to  altered  pressure,  and  in  time  the 
vertebral  bodies  will  be  found  thicker  on  one  side  than  the  other,  and 
changes  in  the  shape  of  the  articulating  and  transverse  processes  will 
also  take  place.  Distortion  in  the  shape  of  the  bodies  also  occurs  from 
osseous  growth  to  meet  abnormal  pressure,  as  has  been  shown  by  Wolff. 
As  has  already  been  stated,  a  twist  takes  place  in  the  spinal  column,  and 


Fig.  108.— Individual  Vertebrae  Altered  in  Lateral 
Curvature.    (Sehreiber.) 


-Individual  Vertebra?  Altered  in  Lateral 
Curvature.    (Sehreiber.) 


consequently  the  transverse  processes  are  out  of  the  normal  plane ;  the 
ribs  follow  the  transverse  processes,  and  a  characteristic  projection  on 
one  side  and  flattening  on  the  other  occur. 

If  the  column  is  curved  laterally  in  two  or  three  directions,  rotation 
necessarily  takes  place  in  different  parts  of  it  in  opposite  directions. 
The  projection  of  the  ribs  is  naturally  more  noticeable  than  the  projection 
of  the  transverse  processes  without  ribs ;  but  in  the  lumbar  region  the 
muscles  are  thrown  forward,  or  recede,  giving  a  characteristic  alteration 
in  the  contour  of  the  trunk. 

The  intervertebral  cartilages  necessarily  twist  with  the  vertebrae  and 
are  compressed  on  one  side  more  than  on  the  other  in  cases  of  marked 
curves ;  but  in  severe  cases  they  will  be  found  on  measurement  thicker 
on  the  side  of  convexity  than  of  concavity,  so  that  instead  of  being  flat, 
they  are  wedge-shaped,  from  side  to  side. 

In  some  cases,  as  has  been  shown  by  Adams  and  others,  the  tips  of 
the  spines  in  severely  rotated  columns  may  be  on  a  straight  line,  while 
the  bodies  are  badly  distorted,  the  axis  of  rotation  being  near  the  spinous, 
processes. 


LATERAL   CURVATURE    OP    THK    SPINK. 


lo7 


For  an  understanding  of  this  torsion,  it  is  well  to  bear  in  mind  that 
the  structure  of  the  spinal  column  is  such  that  a  bending  to  the  side  with- 
out any  twisting  of  the  column  is  possible  only  to  a  limited  extent.  The 
purely  sidewise  motion  of  the  column,  the  only  motion  possible  in  fish,  is 
fully  developed  in  reptiles  and  in  some  animals,  but  is  limited  in  man. 
In  old  people  it  may  be  almost  wanting,  though  in  faital  life  and  in 
infants  it  is  much  more  free. 

A  detailed  anatomical  description  of  the  structure  of  the  vertebrae  is 
hardly  necessary  for  an  understanding  of  the  phenomenon  of  torsion. 

The  individual  vertebras  rotate  on  each  other  to  a  limited  extent;  the 
amount  of  possible  rotation  varying  according  to  age  and  the  condition 
of  the  spine.  The  various 
parts  of  the  spinal  column 
permit  a  different  amount 
of  rotation;  the  upper 
cervical  region  permitting 
the  most,  and  the  lumbar 
region  the  least. 

When  the  demands  of 
the  individual  require  more 


Fig.  110.— Change  in  Shape  of  Bodies 
of  Vertebras.    (ScbreiberJ 


Fig.  111.— Torsion  in  Lateral  Curvature.    (Schreiber.) 


motion  to  the  side  than  would  be  possible  by  the  purely  sidewise  bending 
of  the  column,  this  can  be  gained  by  a  torsion  of  the  column  so  that  the 
freer  antero-posterior  movement  of  it  may  aid  the  limited  side  motion. 

Some  discussion  has  taken  place  as  to  whether  the  torsion  is  primary 
to  the  curve  or  secondary.  Schmidt '  is  of  the  opinion  that  the  torsion  is 
primary,  as  there  is  always  a  curvature  if  torsion  exists,  but  slight  curva- 
ture may  take  place  without  torsion.  The  question  cannot  be  considered 
one  of  great  importance. 

Dr.  Judson's  excellent  experiment  to  demonstrate  the  phenomenon  of 
rotation  is  well  known,  and  can  be  understood  by  a  glance  at  the  accom- 
panying illustrations.     A  flexible  rod  is  passed  through  the  disarticulated 


1  Centralblatt  f.  Chir..  November  11th,  1882. 


108 


ORTHOPEDIC    SURGERY. 


vertebras  of  a  spinal  column,  placed  in  their  normal  order,  one  above  an- 
other, and  kept  in  relative  position  by  means  of  elastic  straps,  secured  to 
uprights.  Increase  of  downward  pressure  demonstrates  rotation  and 
lateral  curvature. 

There  is,  therefore,  necessarily  a  torsion  of  the  spinal  column  when- 
ever it  is  bent  toward  the  side  to  any  considerable  extent;  and  when  a 
curved  condition  of  the  spine  becomes  habitual  or  constant  the  changed 

pressure  in  the  spinal  col- 
/"'      a       -  umn  produces  in  time  al- 

terations in  the  shape  of 
the  vertebral  bodies,  and 
in  the  articulating  surface. 
Lorenz  has  clearly 
shown     that    not    only    do 


Fig.  112.  Fig.  113. 

Figs.  112,  113.  — Judson's  Apparatus  to  Demonstrate  Rotation. 


the  bodies  of  the  vertebra?  give  evidence  of  torsion  around  the  axis  of  the 
spinal  column,  but  there  is,  in  advanced  cases,  evidence  of  torsion  of 
the  bodies  themselves  in  oblique  and  spiral  longitudinal  striatums  on 
the  bodies  in  the  place  of  the  usual  vertical  marking.  Besides  the  ro- 
tation, as  has  been  stated,  the  bodies  grow  in  the  direction  of  the  least 
pressure;  consequently  the  bodies  lose  their  normal  symmetrical  shape; 
the  spinal  canal  becomes  irregularly  oval  in  shape,  and  the  transverse 
and  articular  processes  are  altered  according  to  the  position  of  the  ver- 
tebra? ;    those  on  the  crowded  side  being  broader  and  lower  than  on  the 


LATERAL   CURVATURE   OF   THE    SPINE.  109 

convex  side.  The  shape  of  the  vertebrae  is  indicated  in  the  accompany, 
ing  pictures  (Figs.  110  and  111),  but  it  must  be  borne  in  mind  that  the, 
vertebrae  vary  necessarily  according  to  their  relative  position  in  the  curve 
and  to  the  direction  in  which  they  receive  the  superincumbent  pressure. 

The  alterations  of  the  bones  in  the  vertebral  column  are  not  to  be 
studied  in  the  individual  vertebrae.  The  whole  column  is  twisted  and  all 
the  bones  are  necessarily  altered  according  to  the  abnormal  positions,  as 
a  result  of  those  atrophic  changes  in  bone  which  always  result  from 
abnormal  pressure  or  weight  bearing. 

The  ribs  are  not  only  rotated,  but  altered  in  shape,  as  is  seen  in  the 
accompanying  picture  (Fig.  114).  They  are  also  altered  in  the  line  of 
their  obliquity,  being  lowered  on  the  side  of  the  concavity  of  the  curve. 

The  contour  of  the  thorax  is  changed  from  the  altered  shape  of  the 
ribs;  the  clavicles  remain  unchanged;  but  the  tip  of  the  sternum  may 
be  deflected  from  the  median  line.  The  ribs  project  backward  at  the 
angle  on  the  side  of  the  convexity  of  the  curve  and  forward  in  the  line 
of  the  concavity. 

A  cross  section  of  the  thorax  shows  an  alteration  of  the  diagonal  axes 
of  the  chest,  which  should  normally  be  equal,  but  in  the  ordinary  dorsal 
right  convex  curve  the  diagonal  axis  from  the  left  front  side  to  the  right 
back  side  of  the  thorax  is  longer  than  the  other  side. 

The  different  halves  of  the  thorax,  on  cross  section,  should  be  sym- 
metrical normally,  but  in  lateral  curvature  the  portion  on  the  convex  side 


Fig.  114.— Distortion  of  Ribs  and  Thorax  in  Lateral  Curvature.    (After  Loreuz.) 

is  smaller  than  that  on  the  concave  side,  owing  to  the  flattening  of  the 
ribs.  The  vertebral  bodies  are  also  crowded  into  this  half  of  the  thorax, 
so  that  there  is  less  room  for  expansion  of  the  lung  on  that  side  than  on 
the  other  side. 

In  the  severest  cases  of  distortion,  the  lower  ribs  on  one  side  may  rest 
upon  the  crest  of  the  ilium  or  even  sink  into  the  pelvic  cavity. 

The  muscles  of  the  spinal  column  in  an  early  case  of  lateral  curvature 
are  unaffected,  except  in  cases  of  a  purely  paralytic  nature. 


110  ORTHOPEDIC    SURGERY. 

Adams  found  in  dissections  of  advanced  cases  that  the  muscles  on 
both  sides  of  the  spine  "  were  much  wasted,  reduced  to  very  thin  layers, 
pale  in  color,  and  in  more  or  less  advanced  stages  of  fatty  degeneration, 
which  probably  commences  in  the  muscles  in  the  concavity  of  the  curve, 
those  on  the  convexity  wasting  at  a  much  later  period."  (The  muscles 
in  the  concavity  of  the  curve  are  found  neither  prominent  nor  rigid.) 

In  advanced  cases  of  lateral  curvature,  the  ligaments  on  the  concave 
side  of  the  spinal  column  are  shortened  and  those  on  the  convex  side  are 
elongated.  This  is  the  result  of  adaptive  shortening  of  them,  and  is  not 
found  in  the  early  stages  of  the  affection. 

Distortion  of  the  Pelvis  in  Cases  of  Lateral  Curvature  of  the  Spine. — 
The  pelvis  is  not  necessarily  distorted  in  lateral  curvature  of  the  spine, 

but  the  bones  of  the  pelvis  may,  if  not 
sufficiently  unyielding  in  their  structure, 
become  altered  by  abnormal  pressure  or 
strain.  The  pelvis  may  assume  the  posi- 
tion of  obliquity  from  a  prominence  of 
one  hip  due  to  the  uncovering  of  the  crest 
of  the  ilium  by  the  over-projecting  ribs, 
but  true  obliquity  is  exceptional. 

When  there  is  irregularity  in  the 
length  of  the  legs,  obliquity  of  the  pelvis 
necessarily  exists.  The  prominence  and 
rigidity  of  the  spinal  muscles  in  the  lum- 

Fig.   llo.— Distorted  Pelvis  in    Lateral  .  „  , 

curvature.  bar    region    frequently  seen    on  the  con- 

vexity of  the  sharp  lumbar  curve  often 
convey  to  the  touch  a  doubtful  sense  of  fluctuation,  and  have  frequently 
led  to  the  suspicion  of  an  abscess.  The  spinal  cord  is  not  affected  by 
lateral  curvature. 

The  spinal  nerves  in  consequence  of  the  large  size  of  the  foramina  are 
not  liable  to  suffer  compression  except  in  cases  of  great  distortion. 

Influence  of  Lateral  Ctcrvature  in  Causing  Displacement  of  Abdominal 
Viscera. — The  abdominal  viscera  are  less  likely  to  be  displaced,  even  in 
severe  cases,  than  the  thoracic  organs,  though  the  liver  may  be  out  of 
place  and  altered  in  form,  according  to  the  direction  and  extent  of  the 
spinal  distortion.  The  spleen  may  suffer  some  compression,  and  the  aorta 
is  necessarily  displaced ;  Adams  reports  a  case  in  which  at  a  post-mortem 
examination  he  was  barely  able  to  pass  the  hand  between  the  bodies  of 
the  vertebrae  and  the  ribs.  The  lung  on  the  convexity  of  the  curve  is, 
therefore,  much  more  compressed  and  flattened,  and  the  thoracic  cavity  on 
the  concavity  of  the  curve  is  always  found  to  be  much  larger  than  would  be 
expected.  The  lung  on  the  concavity  of  the  curve  may  be  altered  in  form, 
but  is  not  diminished  in  bulk  as  on  the  side  of  convexity.  The  heart  is 
generally  found  displaced  toward  the  concavity  of  the  curve  in  severe  cases. 


LATERAL   CURVATURE   OP   THE   SPINE.  Ill 


Diagnosis. 

A  diagnosis  of  lateral  curvature,  in  a  severe  case,  is  so  simple  that  an 
inspection  of  the  patient  is  all  that  is  required. 

In  the  less-marked  cases,  however,  the  recognition  of  the  true  nature 
of  the  deformity  is  not  so  easy,  and  a  careful  examination  is  necessary, 
not  only  for  the  exclusion  of  other  affections  of  the  spine,  but  also  for  an 
insight  into  the  stage  and  progress  of  the  lateral  curvature,  and  the 
amount  of  rotation  and  bony  change  in  the  spinal  column. 

The  method  of  examination  of  a  case  of  lateral  curvature  is  as  follows: 

The  patient's  back  should  be  bared  to  the  level  of  the  trochanters, 
and  the  arms  should  be  allowed  to  hang  free.  The  most  natural  attitude 
in  standing  should  be  noted  and  also  the  position  of  the  patient  in  an 
attempt  to  stand  in  as  straight  a  position  as  is  possible ;  the  tips  of  the 
spinous  processes  are  to  be  marked  with  a  crayon  and  also  the  ends  of 
the  scapulae.  To  determine  the  central  line  a  string,  to  which  a  slight 
weight  is  attached,  is  hung  from  the  seventh  cervical  vertebra  (to  which 
it  can  be  fixed  by  a  piece  of  adhesive  plaster),  the  string  being  long 
enough  to  hang  to  the  cleft  of  the  buttock.  The  distance  of  the  tips  of 
the  scapulae  (the  arms  being  crossed  in  front  of  the  chest)  from  this  cen- 
tral line  should  be  measured,  and  also  the  distances  from  this  line  to  the 
points  of  greatest  curvature  of  the  line  of  the  spinous  process.  These 
points  being  noted,  the  slope  of  the  shoulders,  the  outlines  of  the  sides  of 
the  trunk,  and  the  contour  of  the  back,  as  well  as  any  lack  of  symmetry 
or  unilateral  fulness,  should  be  carefully  recorded,  both  when  the  patient 
is  standing  and  in  the  stooping  position,  with  the  back  well  arched.  If  a 
deviation  of  the  line  of  the  spinous  processes  is  observed,  a  lack  of  sym- 
metry of  outline,  or  a  unilateral  projection  of  the  ribs  or  scapulae,  in  the 
erect  position,  the  patient  should  be  suspended  by  means  of  a  head  sling 
and  also  made  to  lie  in  a  recumbent  position  upon  the  face.  A  marked 
alteration  of  the  curvature,  contour,  or  outlines  following  removal  of  the 
superincumbent  weight  is  of  particular  importance. 

The  inspection  of  the  arched  back,  stooping  from  a  sitting  position,  is 
important ;  any  rotation  of  the  fixed  ribs  due  to  osseous  change  is  easily 
detected  in  the  lack  of  symmetry  and  projection  of  one  side  more  than 
the  other. 

The  flexibility  of  the  spine  should  be  tested  by  causing  the  patient  to 
stand  first  with  one  foot,  and  then  the  other  upon  a  series  of  blocks  half 
an  inch  in  thickness,  and  testing  what  height  can  be  placed  under  the 
patient's  foot  without  preventing  her  from  standing  upon  both  legs  with 
the  limbs  straight  and.  without  flexion  at  the  knee ;  this  tests  the  lateral 
flexibility  in  the  lower  part  of  the  spinal  column.  In  testing  the  flexi- 
bility higher  up,  the  patient  should  be  seated  on  a  stool,  and  one  hand 


112 


ORTHOPEDIC    SURGERY. 


"TV 


of  an  assistant  be  placed  upon  her  side,  above  the  crest  of  the  ilium, 
while  the  other  hand  should  be  placed  upon  the  crest  of  the  ilium.     The 

patient  should  then  be  directed  to  bend 
sideways  toward  the  side  of  the  higher 
hand,  and  the  amount  of  this  motion, 
without  tilting  of  the  pelvis,  is  to  be 
noted. 

The  lateral  flexibility  can  be  often 
readily  seen  by  directing  the  patient  to 
bend  to  one  side,  keeping  the  legs  straight 
and  avoiding  twisting  the  pelvis. 

The  amount  of  possible  rotation  of 
the  spine  may  also  be  of  importance; 
in  which  case  the  patient  should  sit  upon 
a  revolving  stool  with  the  shoulders 
held  firmly  by  an  assistant  when  the 
amount  of  possible  revolution  of  the 
stool  in  one  direction  or  another,  without 
turning  the  shoulders,  can  be  approxi- 
mately estimated. 

It  is  not  always  necessary  to  examine 
the  front  of  the  patient's  trunk.  When 
this  is  done,  the  projection  of  the  ribs  in 
front,  and  the  difference  in  the  promi- 
nence or  flatness  of  the  two  breasts,  the 
deviation  of  the  tip  of  the  sternum  and 
of  the  umbilicus  from  the  median  line 
are  of  importance,  as  indicating  the 
amount  of  structural  change  which  has 
taken  place. 

The  strength  of  the  muscles  of  the 
patient's  back  may  be  tested  by  means 
of  a  dynamometer,  or  spring  balance, 
and  the  height  and  weight  should  be  re- 
corded and  compared  with  the  normal 
standard  for  the  age  as  given. 

A  diagnosis  of  lateral  curvature  in 
the  early  stage  is  to  be  made  by  ob- 
serving in  any  case  an  habitual  lack  of  symmetry  in  the  outline  of  the 
sides  of  the  trunk,  the  slope  of  the  shoulders,  or  contour  of  the  back,  in 
the  unnatural  projection  of  one  shoulder  blade  or  a  portion  of  the  trunk 
on  one  side  or  of  one  hip ;  and  on  a  constant  deviation  of  the  line  of  the 
spinous  processes  from  the  vertical  line. 

An   accidental  assumption  of  any  position  with  the  prominence  of 


PIG.  llti.— Lumbar  Flexibility  of  the  Spine. 


LATERAL    CURVATURE    OK    THK    SPINK. 


113 


these  symptoms  does  not  necessarily  constitute  lateral  curvature;  but  the 
constant  habitual  assumption  of  such  a  position,  when  the  patient  stands 
in  the  attitude  of  ease  and  greatest  comfort,  must  be  regarded  as  a  lateral 
curvature  either  of  a  flexible  or  fixed  type. 

Adams  and  Fisher  claim  that  a  distinction  should  be  made  between 
deviations  and  curvatures  of  the  spinal  column,  and  state  that  much  of 
the  confusion  regarding  causation  and  the  results  of  treatment  is  from 
a  lack  of  this  important  distinction.  This  distinction,  however,  is  not 
always  a  practical  one,  as  in  the  early  stage  of  lateral  curvature  before 
fixation  has  occurred  permanent  rotation  is  not  always  recognizable. 

The  amount  of.  fixed  rotation  is  best  indicated  by  the  amount  of  uni- 
lateral projection  of  the  ribs  at  the  level  of  the  shoulder  or  in  the  hollow 
of  the  back  when  the  patient  bends  forward  or  is  recumbent. 

The  amount  of  osseous  and  ligamentous  change  is  indicated  by  the 
amount  of  stiffness  or  the  slight  change  in  the  curves  and  asymmetrical 
symptoms  as  the  patient  alters  the  position  standing,  lying,  or  in  suspen- 
sion. 

In  this  way  it  is  possible  to  determine  the  amount  of  progress  the 
distortion  has  made,  and  the  stage  of  the  affection. 

A  notable  error  in  the  diagnosis  of  lateral  curvature  is  recorded  by 
Mr.  Adams  in  the  practice  of  surgeons  of  the  last  generation,  which 
seems  hardly  possible  at  the  present  time.  The  relaxed  muscles  in  the 
lumbar  region  in  a  case  of 
severe  lateral  curvature  were 
mistaken  for  a  deep  abscess, 
and  operative  measures  were 
advised  by  several  surgeons 
of  prominence.  The  subse- 
quent result  proved  the  swell- 
ing to  be  purely  the  deep 
muscular  tissue  in  the  loin 
made  prominent  by  the  ro- 
tated transverse  vertebrae  on 
the  convexity  of  a  lumbar 
curve. 

The  writers  can  record  a 
large  dorsal  lateral  curve 
with  severe  rotation  of  the 
ribs  which  was  mistaken  by 

a  physician  (a  skilled  specialist  in  diseases  of  the  chest)  for  an  obscure 
form  of  pleural  effusion. 

Lateral  curvature  is  not  infrequently  confounded  with  caries  of  the 
spine  through  simple  ignorance  of  the  nature  of  either  affection,  both  being 
classed  as  chronic  spinal  affections.      In  pronounced  lateral  curvature, 


117.— Projection  of  Side  of  Thorax  in  Lateral  Curva- 
ture, Seen  when  Back  is  Bent. 


1U 


ORTHOPEDIC   SURGERY 


the  lateral  twist  and  the  rotation  are  essentially  different  from  the  curve 
of  Pott's  disease,  which  is  chiefly  an  ante ro- posterior  curve.  In  the 
former,  rotation  is  an  unmistakable  symptom ;  in  the  latter,  it  is  absent 
or  slight.  In  the  slighter  cases  of  lateral  curvature  the  spine  is  flexible, 
and  the  lateral  curve  diminishes  or  disappears  on  recumbency;  and  there 
is  never  a  sharp  angular  projection.  In  Pott's  disease  the  spine  is  not 
flexible  but  stiff,  the  curve  is  angular,  and  it  does  not  disappear  on 
recumbency. 

Methods  of  Kecording  Lateral  Curvature. 

For  clinical  purposes  a  careful  record  of  lateral  curvature  is  necessary. 

In  recording  lateral  curvature  it  is  necessary  to  note  the  flexibility  of 

the  spine,  the  curve,  and  the  amount  of  twist  or  rotation.     Nothing  is 

better  than  photographs  carefully 
taken.  For  this  purpose  the  spi- 
nous processes  should  be  marked, 
and  a  line  drawn  from  the  anterior 
superior  spine  to  the  cleft  of  the 
buttocks,  which  may  be  termed  the 
median  line  of  the  body.  The 
patient  if  standing  should  be  placed 
squarely  before  a  camera  and  pho- 
tographed with  such  arrangement 
of  light  as  to  prevent  strong 
shadows.  A  photograph  should 
also  be  taken  with  the  patient  re- 
cumbent upon  a  hard  surface  with 
the  anterior  superior  spines  and 
the  shoulders  in  contact  with  the 
surface  upon  which  the  patient  lies, 
thus  securing  a  fixed  position;  if 
the  head  is  dropped  over  the  edge 
of  the  table,  the  arms  are  extended 
at  right  angles,  and  the  camera  is 
suitably  placed,  a  photograph  can 
be  taken  in  a  profile  of  the  cross-sec- 
tion of  the  back,  thus  showing  the 
rotation.  The  rotation  can  also  be 
photographed  if  the  standing  pa- 
tient stoops  and  the  camera  is 
focussed  on  the  portion  of  the  back 
showing  the  greatest  rotation  of  the  spine.  If  the  camera  is  placed 
directly  above  the  patient  lying  flat  upon  the  face  and  the  picture  com- 
pared with  that  of  the  standing  position,   the  amount  of  flexibility  of 


Fig.  118.— Thread  Frame  for  Recording  De- 
viations of  the  Spine.  (Children's  Hospital 
Report.) 


LATERAL   CURVATURE    OF   THE   SPINE.  I  1  5 

the  spine  and  of  the  amount  of  fixed  curve  can  be  estimated  by  the 
change  in  the  marked  lines. 

A  more  ready  but  less  reliable  means  of  record  can  be  furnished  by 
the  following  measurements  made  and  recorded  from  the  bony  points  and 
lines  previously  marked  upon  the  back :  First,  the  distances  between  the 
middle  line  and  the  point  of  maximum  curve  of  the  line  of  the  spines  in 
the  upper  and  lower  curve  if  both  exist;  second,  the  distance  from  the 
spine  of  the  seventh  cervical  vertebra  to  the  point  where  the  median  line 
crosses  the  line  of  curve. 

These  measurements,  taken  of  the  patient  lying  and  standing  and 
compared,  indicate  by  their  difference  the  amount  of  fixedness  of  the 
curve,  and  as  they  are  taken  from  anatomical  landmarks  easily  found  are 
of  sufficient  accuracy  for  ordinary  practical  purposes. 

An  accurate  record  of  rotation  is  more  easily  made  if  the  patient  is 
recumbent;  the  muscles  are  relaxed  and  there  is  less  danger  of  error  from 
muscular  effort  of  the  patient.  A  cross  tracing  of  the  back  taken  at  a 
recorded  point  and  at  a  measured  distance  from  the  vertebra  prominens 
is  of  reasonable  accuracy  if  carefully  made. 

Prognosis. 

No  accurate  data  are  in  existence  which  enable  us  to  form  a  definite 
prognosis.  Two  errors  in  prognosis  are  common.  First,  that  the  disease 
is  of  the  most  serious  nature;  second,  that  it  is  a  trivial  affection  and 
will  be  readily  outgrown  by  the  patient.  The  fact  is,  that  in  the  larger 
number  of  these  cases  the  affection  is  a  self-limited  one,  occasioning 
slight  deformity,  which  persists  through  life,  causing  no  trouble  and 
recognized  only  by  the  dressmaker  or  by  some  near  relative. 

In  other  cases,  however,  the  disease  becomes  decidedly  worse  as  the 
deformity  increases,  and  a  pitiable  distortion  follows,  causing  a  great 
deal  of  neuralgic  pain  and  a  marked  deformity. 

It  is  impossible  to  state  positively  in  what  instances  an  increase  of  the 
curve  will  take  place  and  when  they  can  be  relied  upon  to  remain  stationary. 
It  may,  however,  be  said  that  when  the  physical  condition  during  the 
growing  period  remains  constantly  below  the  proper  standard,  and  when 
the  patient's  growth  is  rapid,  an  increase  of  curve  is  to  be  apprehended. 
The  decrease  or  diminution  of  lateral  curvature  from  simple  growth  with- 
out treatment  is  not  to  be  expected. 

Sometimes  the  disease  may  remain  to  a  slight  extent  during  girlhood 
and  early  womanhood,  developing  an  increase  at  a  period  past  middle 
life.  Such  cases  are  rare,  and  are  dependent  upon  a  loss  of  general 
health. 

In  determining  the  prognosis  in  any  given  case  the  following  facts 
must  be  ascertained  and  borne  in  mind : 


11(5  ORTHOPEDIC   SURGERY. 

First,  the  probable  rate  of  growth.  This  can  be  ascertained  by  the 
patient's  height,  the  hereditary  tendency  toward  height  as  ascertained  by 
the  height  of  the  parents  and  the  parents'  families.  The  general  opinion 
is  that  completion  of  growth  exerts  a  powerful  influence  in  arresting 
progress  of  the  curvature.  In  a  girl  of  health  at  the  age  of  twenty,  with 
only  a  slight  degree  of  curvature,  this  may  remain  without  increase  for 
life,  or  for  a  while;  but  there  remains  a  liability  to  increase,  and  Adams 
notes  a  case  in  which  a  patient,  with  a  slight  curvature  up  to  the  age  of 
forty,  developed  a  very  severe  curvature  at  sixty  owing  to  failure  of 
general  health. 

The  physician  should  bear  in.  mind  certain  facts  as  to  the  rate  of 
growth  of  children.  Malling-Hansen, '  as  director  of  the  Royal  Deaf  and 
Dumb  Institution,  has  examined  one  hundred  and  thirty  children,  weigh- 
ing them  at  different  times.  The  boys  were  weighed  at  6  a.m.  and  9  p.m. 
The  girls  were  weighed  once  a  day,  at  2  p.m.  He  found  that  a  child 
might  weigh  from  one  to  two  pounds  heavier  at  night  than  in  the  morn- 
ing, and  be  more  than  one  pound  and  a  half  lighter  in  the  morning  than 
it  was  in  the  evening  before  exercise.  Bathing  did  not  influence  the 
weight.  There  was  always  an  increase  after  a  full  meal.  He  found  that 
there  were  three  periods  in  which  the  weight  varied :  first,  a  period  of 
decrease  from  the  middle  of  May  in  each  year  to  the  middle  of  July ;  a 
period  of  increase  of  great  importance  from  the  middle  of  July  to  the 
middle  of  November;  and  then  a  period  in  which  the  child's  weight  in- 
creased slightly,  but  often  remained  stationary,  and  might  even  diminish, 
from  the  middle  of  November  to  the  middle  of  May.  Temperature  had 
an  effect  upon  increase  and  decrease,  increase  of  temperature  being  accom- 
panied by  increase  in  weight,  and  vice  versa.  Boys  consumed  one-fifth 
more  than  girls. 

In  general  it  may  be  said  that  if  a  patient  has  gained  full  height  and 
development  in  figure,  any  increase  in  growth  is  not  often  to  be  expected, 
and  that  an  increase  in  curve  is  not  probable  after  the  osseous  system  has 
become  thoroughly  formed. 

The  conclusions  of  Pravaz  are  well  expressed,  who  considers  that 
"the  patient's  general  condition  is  of  great  importance  in  the  prognosis 
of  lateral  curvature.  Chlorosis  and  imperfect  nutrition  are  unfavorable 
to  the  re-establishment  of  the  figure.  In  general,  recovery  of  the  figure 
is  more  to  be  expected  in  younger  than  in  older  patients,  but  the  writer 
wishes  to  warn  against  the  prevalent  idea  that  patients  will  grow  out  of 
a  curve  of  the  spine.  The  prognosis  in  curvature  following  phthisis  is 
unfavorable,  and  distortions  due  to  disturbances  of  muscular  action  are 
often  very  difficult  to  treat,  and  rickety  distortions  are  more  unfavorable 
for  treatment  than  those  due  to  a  loss  of  flexibility  of  the  spine  in  chil- 

1  Brit.  Med.  Journ.,  September  20th,  1884. 


LATERAL   CURVATURE    OF    THE    SPINK. 


117 


dren  at  the  time  of  the  second  dentition  or  puberty.  Curvatures  sub- 
mitted to  treatment  at  an  early  stage,  even  when  quite  pronounced,  may 
become  corrected  provided  the  patient's  general  condition  is  good,  the 
prognosis  depending  in  a  large  measure  upon  the  amount  of  rotation  of 
the  vertebrae  present,  rather  than  on  the  amount  of  the  curve.  Curva- 
tures in  the  lumbar  region  are  less  favorable  than  those  in  the  dorsal 
region,  and  curvatures  with  a  long  radius  are  more  readily  straightened 
than  those  with  a  short." 

The  normal  height  and  weight  of  male  and  female  are  here  given  for 
the  sake  of  reference. 


Table  of  Height  and  Weight  of  the  Huiman  Body. 

Male. 


Age 

At  birth 

1  year  

2  years  .    . . . 

3  "     

4  "      

5  «      

6  "      

7  "      

8  "      

9  "      

10  "      

12  "      

14  "      

1(5  «      

18  "      

20  "  .       .. 

25  "      

80  "      

40  "      


Height  in  Feet  and  Inches. 


1  ft. 

2  " 
2  " 

2  " 

3  " 
3  " 
3  " 


(0.496 
(0.696 
(0.797 
(0.860 

.(0.932 
(0.990 
(1.046 
(1.112 
(1.170 

.(1.227 
(1.282 
(1.359 
(1.487 
(1.610 
(1.700 
(1.711 
(1.722 
(1.722 
(1.713 


Weight. 


7  lbs. 


2(J 
29 

36 

39 

44 

49 

53 

57 

68 

89 

117 

135 

143 

150 

152 

151 


(  3.20kgm.) 

(10.00 

(12.00 

(13.21 

(15.07 

(16.70 

(18.04 

(20. 16 

(22.26 

(24.09 

(26.12 

(31.00 

(40.50 

(53.39 

(61.26 

(65.00 

(68.29 

(68.90 

(68.68 


Female. 


Age 

At  birth 

1  year  

2  years  

3  "  

4  «  

5  "  

6  "  

7  "  

8  «  

9  "  

10  "  

12  "  

14  "  

16  "  ... 

18  " 

20  "      

25  "      

30  " 

40  « 


Height  in  Feet  and  Inches. 

1  ft.     6  in 

.  (0.483  m.) 

2  ' 

3 

(0.690  "  ) 

2  ' 

6   " 

(0.780  "  ) 

2  ' 

9  " 

(0.850  "  ) 

3  ' 

.(0,910  "  ) 

3  ' 

2  " 

(0.974  "  ) 

3  ' 

4  " 

(1.032  «  ) 

3  ' 

7   " 

(1.096  "  ) 

3  ' 

9  " 

(1.139  "  ) 

3  ' 

11   " 

(1.200  "  ) 

4  < 

1   " 

(1.248  "  ) 

4  « 

4  " 

(1.327  "  ) 

4  ' 

9  " 

(1.447  "  ) 

4  ' 

11   " 

(1.500  "  ) 

5  ' 

1   " 

(1.562  "  ) 

5  ' 

2   " 

(1.570  "  ) 

5  ' 

2   " 

(1.577  "  ) 

5  ' 

2   " 

(1.579  "  ) 

5  ' 

I   " 

(1.555  "  ) 

Weight. 


6  lbs. 

20  " 

25  " 

27  " 

31  " 

34  " 

37  " 

40  " 

43  " 

50  " 

53  " 

67  " 

84  " 

98  " 

117  " 

120  " 

121  " 
121  " 
129  " 


(  2.91  ks;iu. 

(  9.30  « 

(11.40  " 

(12.45  " 

(14.18  " 

(15.50  " 

(16.74  " 

(18.45  " 

(19.82  " 

(22.44  " 

(24.24  " 

(30.54  " 

(38.10  " 

(44.44  " 

(53.10  " 

(54.46  " 

(55.08  " 

(55.14  " 

(58.45  " 


118  ORTHOPEDIC    SURGERY. 

The  prognosis  is  not  good,  so  far  as  improvement  of  the  curve  is  con- 
sidered, in  paralytic  and  rhachitic  cases. 

The  lateral  curvature  seen  in  early  Pott's  disease  is  easily  corrected 
by  the  proper  treatment  for  caries  of  the  spine.  The  deformity  which 
comes  on  in  the  later  stages  and  is  dependent  on  osseous  change  is  irre- 
mediable. 

Preventive  Measures. 

As  faulty  attitudes  exert  an  important  influence  in  causing  lateral 
curvatures,  the  avoidance  of  these  is  of  importance  in  preventing  curves. 
The  attitude  assumed  in  sitting  is  necessarily  of  great  importance. 

Schenk  '  has  studied  the  attitude  in  writing  assumed  by  200  school 
children.  In  160  the  trunk  was  found  inclined  with  a  convexity  of  a 
lower  dorsal  curve.  In  34  the  trunk  inclined  toward  the  right,  but  the 
body  twisted  toward  the  left.  In  only  6  was  there  no  twist  of  the  body. 
In  only  38  was  the  transverse  axis  of  the  body  parallel  with  the  desk, 
and  in  the  others  the  pelvis  was  twisted  obliquely  to  the  right. 

t  Scudder'  has  demonstrated  the  injurious  effects  of  imperfect  school 
seating  in  the  Boston  schools. 

The  writers  have  taken  the  opportunity  to  examine  the  attitude  assumed 
in  writing  by  sixty-seven  healthy  adult  males,  while  writing  in  a  three- 
hour  written  examination.  At  the  end  of  two  hours  the  attitudes  were 
observed.  In  all  the  paper  was  inclined  slightly,  so  that  the  written  line 
formed  an  angle  with  the  cross  axis  of  the  thorax.  This  angle  varied  from 
ten  degrees  to  a  right  angle.  The  inclination  of  the  paper  was  always 
such  that  the  right  upper  corner  was  in  front  of  the  left.  In  a  large 
majority  of  the  writers  the  left  side  of  the  hip  was  in  front  of  the  right, 
the  left  shoulder  in  front  of  the  right,  but  the  left  ear  was  usually  slightly 
lower  than  the  right  and  somewhat  behind  it.  In  all  cases,  therefore, 
there  was  a  slight  rotation  of  the  spinal  column.  The  trunk  in  three- 
fourths  of  the  writers  was  inclined  to  the  left,  in  about  one-quarter  to  the 
right,  .and  in  the  remainder  it  was  held  erect. 

It  may  be  fairly  assumed  that,  if  a  twist  of  the  spinal  column  is  inva- 
riable in  writing  in  strong  men,  faulty  attitudes  Avill  be  equally  common 
in  weakly  children. 

The  proper  attitude  during  writing  is  with  the  transverse  axis  of  the 
trunk  parallel  with  the  edge  of  the  writing  table.  The  forearms  should 
rest  at  least  two-thirds  of  their  length  upon  the  table.  The  trunk  should 
be  held  erect,  the  legs  should  be  straight  before  the  trunk,  and  the  feet 
should  rest  upon  a  sloping  cricket  which  rests  and  steadies  the  legs. 


1  "Zur  Aetiologie  der  Scoliosis,"  Berlin,  1885. 

2  Report  Boston  School  Committee,  1890. 


LATERAL   CURVATURE    OP    THK    SPINK.  L19 

The  proper  attitude  in  writing  in  schools  is  favored  by  teaching  the 
perpendicular  in  place  of  slanting  writing. 

Seats. — Chairs  used  by  children  frequently  do  not  properly  support 
the  back  muscles,  which  may  be  unduly  stretched  and  thereby  weakened. 
Children  often  assume  faulty  attitudes  simply  for  the  reason  that  proper 
support  is  not  furnished  the  lower  part  of  the  back. 

A  fruitful  source  of  faulty  attitudes  in  sitting  is  furnished  by  chairs, 
which,  not  fitting  the  child  or  supporting  the  back  properly,  induce  the 


Fig.  119.— School  Bench  and  Seat  with  Support  for  Hollow  of  Back.    (From  Schreiber,  after  Lickroth.) 


patient  to  sit  sideways,  the  trunk  being  supported  on  one  tuberosity  of 
the  ischium.  The  seat  of  the  chair  in  which  the  child  is  to  sit  for  any 
length  of  time  should  not  be  deeper  than  the  length  of  the  thighs  or  higher 
than  the  length  of  the  legs ;  its  back  should  not  be  above  the  shoulders 
and  should  be  arched  so  as  to  fit  in  the  hollow  of  the  back;  or  if  this  is 
not  practicable,  hard  cushions  or  false  chair  backs  made  of  leather  stiffened 
with  steel  should  be  placed  in  the  back  of  the  chair  so  fitted  as  to  act 
as  a  proper  support. 

For  children  with  weak  backs  it  is  advisable  that  the  lower  part  of 
the  back  should  be  well  supported.  If  this  is  not  done,  the  large  mus- 
cles of  the  back  will  be  unduly  strained,  as  they  are  inserted  into  the 
broad  fascia,  which  is  attached  to  the  sacrum  and  iliac  bones,  and  faulty 
attitudes  will  be  instinctively  assumed  by  the  patient.  This  is  shown  if 
tracings  be  taken  of  the  back  of  a  child  in  the  various  attitudes  of  sitting, 
leaning  forward,  backward,  and  sitting  unsupported. 

The  back  of  the  chair  should  slope  backward  slightly,  forming  an 
angle  of  100°  to  110°  with  the  seat.  The  back  of  the  chair  should  be 
arched  with  the  convexity  forward,  the  greatest  convexity  corresponding 
to  the  physiological  curve  in  the  hollow  of  the  back.      The  back  of  the 


120 


ORTHOPEDIC    SURGERY. 


chair  should  be  constructed  so  that  it  will  serve  as  a  comfortable  support 
to  the  whole  spine  when  the  child  leans  backward.  The  backs  of  most 
chairs  simply  touch  the  shoulders  of  children  in  the  upper  dorsal  region. 
Liebreich's  school  chair  is  designed  to  meet  this  end.  Staffel  has 
advised  the  use  of  a  lumbar  back  rest,  which  can  be  secured  to  a  chair  at 
a  proper  height;  it  should  be  narrow  enough  to  fit  into  the  lumbar  region. 
The  following  measurements  are  adapted  from  Staffel-*1 


I. 

6-9 
years. 

Height  from  seat  to  floor 33  cm. 

Height  from  seat  to  middle  of  lumbar  pro- 
jection of  chair 21    " 

From  edge  of  seat  to  vertical  line  drawn  from 

lumbar  projection  to  seat 26    " 


II. 

9-12 
years. 

37  cm. 


30 


III. 

12-15 
years. 

41  cm. 
25    " 
34    " 


IV. 

Adult. 

47  cm. 
27    " 
38    " 


The  picture  illustrates  a  form  of  school  chair  which  will  be  found 
to  support  the  hollow  of  the  back.     The  writing  table  should  be  at  a 

height  proportionate  to  the  height 
of  the  person  sitting.  The  dis- 
tance from  the  top  of  the  seat  to  the 
top  of  the  table  should  be  one-eighth 
of  the  height  of  a  girl,  and  one- 
seventh  of  that  of  a  boy.  The 
height  can  also  be  determined  in 
the  following  ready  way :  The  dis- 
tance from  the  olecranon  of  the 
bent  arm  to  the  seat  with  two  in- 
ches added  should  be  the  distance 
from  the  seat  to  the  top  of  the 
desk.  The  edge  of  the  table 
should  be  just  over  the  edge  of  the 
chair.  The  inclination  of  the  top 
of  the  desk  should  be  a  slope  of  two 
inches  in  a  breadth  of  twelve. 

A  chair  furnishing  support  to 
the  back  and  permitting  a  change 
of  position  without  loss  of  support 
has  been  devised  by  Professor 
Miller  of  the  Massachusetts  Institute  of  Technology  and  Dr.  Stone  of 
Boston  (Fig.  120). 2 

Attitude  during  Sleejy. — The  attitude   during  sleep  is  of  importance. 


Pig.  120.  -  School-chair. 


'Staffel:  Centralblatt  f.  orthop.  Chir.,  May  1st,  1885. 
2 Trans.  Amer.  Orthopedic  Assn.,  vol.  xii. 


LATERAL   CURVATURE   OF   THE   SPINE.  121 

Ta  determine  the  attitudes  usually  assumed  by  children,  the  accompany- 
ing observations  were  made  by  Brackett,  who  was  allowed,  by  the  cour- 
tesy of  the  superintendent,  to  examine  the  decubitus  of  the  chidren  in  the 
Marcella  Street  Home,  Boston. 

Three  hundred  and  twenty  healthy  children  were  observed  with  refer- 
ence to  the  decubitus  while  asleep.  Of  this  number  156  were  boys,  164 
girls.  The  majority  were  between  six  and  fourteen  years  of  age,  and  all 
between  four  and  sixteen.  It  was  noted  whether  the  child  was  lying  on 
the  back,  side,  or  stomach.  In  many  instances  the  decubitus  was  so  nearly 
dorsal  that  it  was  a  question  under  what  head  it  should  be  placed,  but  none 
were  considered  as  lying  on  the  side  unless  the  position  was  such  that  the 
pressure  was  borne  on  one  side  of  the  thorax.  In  about  three-fourths  of 
the  number  seen,  the  position  was  easy,  the  body  straight,  and  head  on 
the  pillow.  In  several  the  head  was  so  thoroughly  wrapped  in  the 
blanket  that  it  could  not  be  removed  without  almost  shaking  the  child 
out.  Among  those  not  lying  on  the  back,  the  favorite  position  was  on 
the  side,  with  the  knees  drawn  up  nearly  to  the  abdomen,  and  the  head 
bent  forward  toward  the  thorax.  Among  the  girls,  this  position  was 
more  common  and  more  extreme.  One  position  was  seen  closely  resem- 
bling that  of  the  fetus  in  utero.  The  child,  a  boy  of  five,  was  sitting  on 
the  right  buttock,  with  the  body  thrown  forward  and  to  the  right  side, 
with  the  knees  in  apposition  to  the  thorax,  and  the  feet  crossed.  The 
head  had  fallen  forward,  the  face  resting  on  the  knees,  one  arm  lay 
across  the  chest,  the  right  seeming  to  be  under  the  side.  In  this  position 
the  child  was  soundly  asleep,  and  required  a  shaking  to  be  aroused. 

The  figures  show  the  positions  to  be  about  equally  distributed  among 
the  three — back,  right  and  left  side,  except  with  the  boys  from  ten  to 
fourteen,  among  whom  there  were  a  majority  on  the  back.  In  the  others 
the  age  did  not  seem  to  influence  the  tendency. 

Age. 

Boys 4-7 

"        10-15 


Girls 4-8 

"        8-10 

"      8-12 

"  9-14 


Back. 

R. 

L. 

Stomach. 

21 

24 

15 

4 

41 

20 

21 

7 

62 

44 

39 

11 

13 

14 

15 

2 

12 

17 

12 

1 

19 

20 

10 

2 

7 

8 

6 

0 

51         59        49 


Dr.  Hare,  of  Boston,  examined  the  decubitus  of  the  healthy  inmates 
in  one  of  the  penal  institutions  of  Boston,  recording  the  positions  observed 
after  10  p.m.,  that  is,  from  one  to  two  hours  after  the  time  the  inmates 
went  to  bed. 

The  results  were  as  follows : 


122 


ORTHOPEDIC    SURGERY. 


Stomach . 


Men  .  . 
Women 
Boys  .  . 


Lay 
on  Hack. 


536 

136 

68 


Lav  <>n 
the  Right  Side. 


384 
74 
73 


Lav  on 
the  Left  Side. 


321 
56 

15 


The  decubitus  of  the  boys  iu  this  table  is  to  be  noticed. 

The  frequency  of  the  decubitus  on  the  right  side  is  quite  marked,  and 
is  explained  by  the  fact  that  the  boys  were  all  required  to  lie  upon  the 
right  side  when  they  went  to  sleep  to  prevent  conversation ;  two  hours 
later  some  had  turned  on  the  face,  some  upon  the  left  side. 

It  will  be  seen  that  the  most  common  attitude  in  sleep  is  upon  the 
side,  but  that  decubitus  upon  the  back  is  more  common  than  on  either 
single  side.  The  right  side  is  more  commonly  lain  on  than  the  left,  but 
the  difference  is  slight ;  young  children  and  men  not  infrequently  lie  upon 
the  belly,  but  the  attitude  is  not  assumed  by  women  or  growing  girls. 

The  fact  that  a  right-sided  decubitus  is  to  be  avoided  in  a  right  dorsal 
convex  curve  makes  these  facts  of  value. 

Faulty  attitudes  are  frequently  assumed  in  walking  and  in  standing, 
especially  by  young  children.  The  habit  of  standing  upon  one  leg  is 
usually  a  habit,  but  in  some  cases  it  may  be  due  to  a  muscular  weakness 
of  one  limb  or  of  a  knee  or  ankle.  The  habit  is  to  be  corrected,  if  pos- 
sible, by  drill  or  by  muscular  exercise. 

In  ordinary  cases  the  precautions  at  night  which  should  be  observed 
are  that  the  patient  should  not  be  allowed  to  sleep  with  many  pillows, 
and  that  the  bed  should  be  a  firm  one.  The  child  should  not  be  allowed 
to  assume  a  twisted  position,  but  should  lie  upon  the  back  or  the  side  of 
the  greatest  concavity.  In  threatening  cases  measures  are  necessary  to 
preserve  a  proper  position.  This  can  be  done  by  means  of  bed  frames, 
described  under  caries  of  the  spine. 

Much  has  been  said  about  the  injurious  effects  of  corsets,  and  there 
is  no  doubt  that  the  muscles  of  the  trunk  are  weakened  by  the  wearing  of 
them. '  The  custom  is  at  present  so  prevalent  that  it  is  difficult  to  pre- 
vent patients  from  wearing  corsets  unless  under  fear  of  immediate  injury. 
The  injury  from  compression  may  be  made  less  by  seeing  that  the  lacings 
are  elastic  and  by  the  use  of  waists  instead  of  corsets.  That  growing  girls 
should  be  furnished  with  clothing  which  does  not  constrict  the  trunk  needs 
no  argument. 

Treatment  of  Lateral  Curvature. 

Several  difficulties  are  to  be  met  with  in  treating  lateral  curvature. 
As  the  affection  is  active  during  the  period  of  growth,  treatment,  to  be 
efficient,  must  be  carried  on  for  a  long  time,  and  this  is  tedious  to  the  sur- 


1  Hutchinson  :  New  York  Medical  Record,  April  27th,  1880,  p.  464. 


LATERAL   CURVATURE    OF    THE    SPINE.  L23 

geon  and  irksome  to  the  patient.  Furthermore,  as  the  disease  is  one  that 
does  not  threaten  life  and  is  slow  and  uncertain  in  its  outcome,  it  is  some- 
times difficult  to  enforce  the  proper  treatment  for  the  requisite  length  of 
time.  Again,  the  distortion  and  danger  vary  at  different  periods  of  the 
trouble,  and  consequently  methods  which  are  necessary  at  certain  stages 
of  the  affection  are  not  needed  later  on. 

As  has  been  said  above,  lateral  curvature  is  a  curve  and  torsion  of  the 
spinal  column,  due  to  the  superincumbent  weight  falling  irregularly  upon 
a  weakened  spinal  column  which  is  constantly  held  out  of  line.  There 
are  four  ways  in  which  an  increase  of  distortion  in  a  growing  spine  can 
be  prevented  : 

1.  By  removing  the  superincumbent  weight. 

2.  By  strengthening  the  weakened  spinal  column. 

3.  By  preventing  the  spinal  column  from  being  held  constantly  out 
of  line. 

4.  By  correction  of  the  curve. 

1.  Removal  of  Superincumbent  Weight. — Recumbency  is  the  only  prac- 
tical way  in  which  removal  of  the  superincumbent  weight  can  be  applied 
for  any  length  of  time,  as  suspension  must  be  a  temporary  measure. 
Recumbency  constituted  the  chief  method  of  treatment  of  the  older  ortho- 
pedic surgeons. 

At  present,  however,  Ave  cannot  consider  that  this  is  a  method  of 
treatment  which  commends  itself  for  continuous  use  in  the  treatment  of 
lateral  curvature,  for,  if  prolonged  for  any  great  length  of  time,  it  neces- 
sarily injures  the  patient's  general  condition,  weakens  the  muscles,  and 
does  not  promote  the  formation  of  solid  bone  in  the  spinal  column,  so  that 
the  weight  can  be  borne  without  the  yielding  of  the  column.  In  cases  of 
very  rapid  growth  or  great  lack  of  muscular  strength,  recumbency,  either 
on  the  back  or  in  the  prone  position,  may  be  advisable  if  carried  out  to 
the  extent  of  rest  for  several  hours  in  the  day. 

The  use  of  a  distracting  force,  which  is  described  in  the  works  of  the 
older  orthopedic  surgeons  with  the  intention  of  obliterating  the  curve  by 
a  direct  pull,  is  inefficient,  as  the  amount  of  force  that  can  be  applied  for 
any  length  of  time  is  not  sufficient  to  effect  substantial  results,  and  unless 
efficient  it  may  be  injurious,  as  in  many  instances  it  Weakens  the  physio- 
logical curves  more  than  the  more  constant  pathological  one. 

The  temporary  use  of  suspension  by  the  head  can  be  added  as  a  means 
of  daily  exercise,  and  can  be  performed  by  means  of  the  head  sling 
attached  to  a  sliding  bar  in  the  ceiling  or  to  a  wheel  carriage.  The  em- 
ployment of  this  method  for  the  sole  and  continuous  treatment  of  lateral 
curvature  is  of  course  impossible,  as  the  disease  ordinarily  runs  its  course 
through  several  years,  but  in  extreme  cases  such  methods  may  be  applied 
temporarily. 

2.  To  Strengthen  the  Weakened  Spinal    Column. — Any    attempts   to 


124  ORTHOPEDIC    SURGERY. 

strengthen  the  bony  structure  in  the  present  state  of  our  therapeutic 
knowledge  must  be  limited  to  the  administration  of  tonics,  and  an  im- 
provement of  the  digestion  and  assimilation,  and  by  encouraging  exercise 
and  fresh  air  as  far  as  it  is  practicable. 

The  spinal  column,  however,  can  be  strengthened  in  its  practical 
power  of  resistance  by  increasing  the  strength  of  the  muscles  which  hold 
it  erect,  by  postural  and  gymnastic  exercises. 

Postural. — The  postural  treatment  consists  in  the  correction  of  faulty 
habits,  the  development  of  weak  muscles,  and  the  retention  of  proper  atti- 
tudes. As  a  raw  recruit  is  taught  the  position  and  carriage  of  the  soldier, 
so  children  are  to  be  drilled  into  standing  and  walking  erect.  This 
method  is  suited  for  the  simplest  cases.  To  be  thoroughly  carried  out, 
it  requires  that  the  patient  should  daily  be  exercised  in  walking,  stand- 
ing, and  sitting  properly  for  a  specified  time  under  the  direction  of  some 
competent  person.  The  principles  of  the  "  setting-up  "  drill  of  recruits 
in  all  armies  are  applicable,  with  modifications,  to  patients  of  this  class. 
When  resting  during  the  hour  of  drill  the  patient  should  remain  recum- 
bent. After  the  drill  is  over,  such  precaution  should  be  taken  as  will 
prevent  the  persistence  for  any  length  of  time  of  a  faulty  attitude.  This 
should  not  be  done  (out  of  the  drill  time)  by  constant  correction,  but  by 
the  proper  arrangement  of  the  play  hours,  and  a  supervision  of  the 
chairs  when  reading  and  studying.  Walking,  running,  and  active  games 
should  be  encouraged,  while  reading,  except  in  proper  position,  should 
be  discouraged.  A  certain  amount  of  time  should  be  given  to  proper  rest 
of  the  back.     Tight  or  constricting  clothing  should  be  avoided. 

The  usual  bad  habits  of  position  are  as  follows :  standing  on  one  leg, 
sitting  at  too  low  a  table,  sitting  in  a  twisted  position,  and  sleeping 
always  on  one  side  with  too  high  a  pillow  for  the  head. 

In  many  early  cases  the  faulty  attitudes  are  clearly  the  result  of  mus- 
cular weakness.  The  increase  in  height  has  not  been  accompanied  by  a 
corresponding  development  in  muscle.  This  condition  is  frequently  met 
in  rapidly  growing  children,  and  is  one  of  the  most  common  causes  of 
lateral  curvature.  Here  proper  gymnastics  are  indicated,  but  they  should 
be  prescribed  and  carried  out  with  much  care.  In  cases  of  gravity,  the 
children  are  unable  to  bear  much  exercise  without  fatigue.  Those  exer- 
cises, therefore,  chiefly  needed  in  correcting  the  deformity  should  be  the 
only  ones  prescribed.  The  usual  class-work  of  the  gymnasia  is  to  be 
avoided,  as  such  cases  require  the  individual  attention  of  a  competent 
person,  who  will  see  that  no  faulty  position  is  taken  during  the  exercises. 

Each  case  may  be  regarded  as  far  as  exercises  are  concerned  as  a  sepa- 
rate problem  to  be  worked  out  individually.  Those  exercises  are  to  be 
given  which  place  and  maintain  the  spine  in  the  best  position.  One  way 
of  accomplishing  this  is  by  determining  first  the  attitude  nearest  to  nor- 
mal which  in  each  individual  can  be  voluntarily  assumed.     This  must  be 


LATERAL   CURVATURE    OF    THE    SPINK.  1^5 

ascertained  by  experiment.     This  attitude  is  called  by  Mr.  Bernard  Both 
the  "keynote  position." 

All  exercises  should  be  done  in  such  a  way  as  to  develop  the  muscles 
involved  in  this  attitude,  or  while  the  attitude  is  maintained.  The  fol- 
lowing are  the  exercises  which  he  prescribes,  varying  in  a  measure  in 
individual  cases  r 

1.  Lying  on  the  back,  arms  by  the  side,  hands  supinated,  very  slow 
deep  inspirations  by  the  nose,  expiration  by  the  mouth. 

2.  The  same,  with  arms  extended  above  the  head. 

3.  Position  the  same  as  No.  1,  head  rotation,  lateral  flexion  of  head. 

4.  Position  the  same,  simultaneous  circumduction  of  both  shoulder 
joints  from  before  backward,  elbows  and  wrists  extended. 

5.  Position  the  same,  one  hip  circumducted  both  ways  (knees  ex- 
tended). 

6.  Lying  on  back,  simultaneous  extension  of  both  arms  upward,  out- 
ward, downward,  from  a  position  of  the  elbows  flexed  and  close  to  the 
trunk. 

7.  Lying  prone,  one  hip  circumducted  both  ways,  knee  kept  extended. 

8.  Sitting  on  couch,  with  the  back  at  an  angle  of  45°,  ankle  circum- 
ducted in,  up,  and  out,  while  the  toes  are  inward  the  whole  time. 

9.  -Lying  on  back  with  arms  extended  upward  by  the  sides  of  the 
head,  flexion  of  both  arms  (surgeon  resisting).  (The  patient's  knees, 
flexed  over  the  end  of  the  table,  fix  the  trunk.) 

10.  Patient  astride  a  narrow  table,  with  the  arms  down  and  hands 
supinated,  trunk  flexion  at  lumbar  vertebrae  (patient  resisting),  followed 
by  trunk  extension  (surgeon  resisting). 

11.  Patient,  with  arms  extended  upward,  leans  against  a  vertical 
post  with  pegs  on  each  side ,  these  he  grasps.  The  surgeon  gently  pulls 
the  patient's  pelvis  forward  by  his  hands  on  the  sacrum  (patient  resist- 
ing), also  pelvis  rotation  on  its  axis  to  right  and  left  alternately  (surgeon 
resisting),  with  the  hands  on  each  side  of  the  pelvis. 

12.  Lying  on  back  with  head  and  neck  projecting  beyond  the  end 
of  table  the  head  is  gently  flexed  by  the  surgeon's  hand  on  occiput  (patient 
resisting).1 

Light  Gymnastics. — It  is  not  a  difficult  matter  to  devise  simple  and 
practicable  exercises  to  develop  the  back  muscles.  The  strength  of  a 
patient's  back  muscles  can  be  determined  in  a  ready  way  by  attaching  a 
cord  to  the  front  of  a  cap  tied  to  the  head,  and  fastening  this  cord  to  a 
spring  balance.  The  patient,  seated  and  strapped  to  a  seat  at  the  proper 
distance  from  the  spring  balance,  held  firmly  by  an  assistant,  is  directed 
to  bend  backward,  keeping  the  back  straight  so  far  as  is  possible,  or  stoop- 

1  British  Medical  Journal,  May  13th,  1882  ;  and  also  Walshani :  St.  Bartholomew's 
Hospital  Reports,  vol.  xx.,  195. 


126  ORTHOPEDIC   SURGERY. 

ing  to  pull  with  straight  legs  upon  a  dynamometer  attached  to  the  floor, 
the  amount  of  the  pull  being  indicated  upon  the  dial. '  A  record  of  this 
registers  any  increase  in  the  strength  of  the  patient,  and  as  a  clinical  fact 
it  will  be  found  that  an  improvement  in  carriage  will  correspond  to  an 
improvement  in  the  indicated  strength. 

The  management  of  cases  of  this  sort  may  be  described  in  a  general 
way  as  follows : 

After  a  careful  inspection  of  the  deformity,  and  an  examination  as  to 
the  flexibility  of  the  curves,  and  examination  of  the  faulty  attitudes,  the 
child's  height  and  weight  should  be  taken  and  a  comparison  made  with 
the  standards  established  by  Bowditch's  tables,"  or  the  tables  of  measure 
for  weight  and  height  mentioned  under  the  head  of  prognosis,  in  order  to 
determine  whether  any  excess  of  growth  in  height  or  deficiency  in  weight 
exists.  It  should  be  considered  that  if  a  child  has  grown  with  unusual 
rapidity,  or  if  the  height  had  increased  without  a  proportionate  increase 
of  weight,  greater  care  should  be  exercised  in  the  management  of  the 
case.  The  patient  should  then  be  directed  and  taught  to  sit  and  stand 
and  walk  in  as  nearly  a  normal  position  as  possible,  and  be  drilled  to 
assume  this  position.  It  should  be  the  object  of  the  attendant  to  see 
that  all  exercises  taken  during  the  exercise  hour  should  be  done  without 
an  assumption  of  a  faulty  attitude.  The  exercises  assigned  should  vary 
in  each  case.  Simple  exercises  not  requiring  special  training  in  any  one 
school  of  gymnastics  are  as  follows : 

1.  The  patient  sits  facing  the  assistant  who  holds  a  strap  passing 
about  the  patient's  occiput  (prevented  from  slipping  by  a  cross  strap 
around  the  head  and  chin) .  The  patient  bends  forward  and  back,  keep- 
ing the  spine  straight.  The  backward  movement  is  resisted  by  the  as- 
sistant. 

2.  Same  as  above,  except  that  the  straps  cross  the  shoulders. 

These  exercises  may  be  carried  on  with  a  weight  and  pulley,  or  rub- 
ber exercising-tubes  instead  of  the  resistance  of  the  assistant,  but  the 
amount  of  force  is  less  readily  regulated.  The  assistant  should  correct 
any  arching  of  the  back. 

3.  The  patient  stands  facing  a  wall  at  arm's  length  from  it;  places 
the  left  hand  upon  the  wall  at  the  height  of  the  chin,  the  hand  being  in 
a  direction  across  the  body.  The  patient,  supported  by  the  arm,  slowly 
brings  the  face  toward  the  arm,  bending  at  the  ankles,  keeping  the  whole 
body  in  line ;  the  face  should  be  turned  so  that  the  left  ear  touches  the 
hand,  and  the  standing  position  slowly  resumed,  the  body  being  still  kept 
from  bending  at  the  hips. 

1  By  fastening  a  spring  balance  to  the  wall,  and  an  arrangement  with  pulleys  and 
cord  connected  to  straps  fastened  to  the  patient,  the  actual  amount  of  force  in  differ- 
ent movements  can  be  estimated. 

2  Reports  of  the  Massachusetts  State  Board  of  Health. 


LATERAL   CURVATURE   OF   THE   SPINE.  127 

4.  The  patient  stands  with  the  heels,  back,  and  occiput  against  a  pro- 
jecting corner  (of  furniture  or  doorway),  and  places  the  elbow  (the  arm 
being  flexed)  as  far  back  as  possible. 

5.  The  patient,  seated  on  a  stool  or  chair,  should  place  the  feet 
behind,  and  on  the  inner  side  of,  the  front  legs  of  the  chair,  and  slowly 
bend  sideways;  the  assistant,  resisting  on  the  head,  determines  the  strain 
on  the  muscles  of  either  side. 

For  children  accustomed  to  stand  upon  one  leg,  the  best  exercise  is  to 
drill  them  to  stand  upon  the  other  for  a  specified  number  of  minutes,  and 
standing  on  one  leg  to  lower  and  raise  the  body,  bending  at  the  knee. 

Exercises  carrying  out  the  principles  advocated  by  Roth  have  been 
recommended  by  Dr.  R.  H.  Sayre, '  who  describes  them  as  follows : 

In  beginning  the  exercises  a  mat  or  thick  shawl  is  laid  on  the  floor 
and  the  patient  lies  prone,  the  arms  at  right  angles  to  the  trunk,  palms 
down,  face  turned  to  the  convex  side,  and  the  back  as  straight  as  possi- 
ble. The  patient  supinates  the  hands,  throws  the  scapulae  well  back, 
raises  the  hands  from  the  floor  and  lifts  the  trunk,  while  the  surgeon 
holds  the  feet  down.  This  is  repeated  three  times;  later  on  it  can  be 
done  oftener.  The  breath  should  not  be  held  during  any  of  these  exer- 
cises, but  the  patient  should  breathe  naturally.  If  necessary  to  secure 
this,  she  can  count  out  loud  while  exercising. 

With  the  hands  behind  the  head,  the  patient  raises  the  elbows  from 
the  floor,  and  raises  the  trunk  as  before,  the  feet  being  held  by  the  surgeon. 

With  the  hands  behind  the  head  and  the  elbows  raised,  the  body  is 
swayed  toward  the  convex  side,  the  patient  trying  to  "pucker  in"  the 
bulging  ribs  and  not  to  bend  in  the  lumbar  concavity.  The  feet  are  fixed 
as  before. 

With  the  arm  on  the  side  of  the  convexity  under  the  body,  the  other 
arm  over  the  head,  the  heels  fixed,  the  patient  raises  the  trunk  from  the 
floor. 

Sometimes  the  arm  on  the  side  of  the  concavity  is  put  on  the  opposite 
buttock  while  the  patient  raises  the  trunk.  Sometimes  the  arm  on  the 
convex  side  is  put  on  the  buttock,  and  in  cases  of  marked  lordosis,  with 
great  stooping  of  the  shoulders,  both  hands  are  put  on  the  buttocks  while 
the  patient  raises  the  trunk. 

The  patient  now  lies  on  the  back,  arms  at  the  sides,  palms  up,  and 
lifts  first  one  foot  in  the  air,  while  the  surgeon  makes  resistance  gradu- 
ated to  the  patient's  power;  repeated,  say,  five  times.  The  same  is  done 
with  the  other  foot,  and  then  with  both.  The  feet  are  next  separated 
and  then  brought  together  once  more  while  the  surgeon  resists.  Each  leg 
then  describes  a  circle,  first  from  within  out,  then  from  without  in. 

If  there  is  special  weakness  at  the  ankles,  with  a  tendency  to  flat-foot, 

1  New  York  Medical  Journal,  November  17th,  1888,  p.  538. 


128  ORTHOPEDIC    SURGERY. 

the  patient  flexes  the  foot  and  extends  it  against  resistance,  and  turns  the 
sole  of  the  foot  toward  its  neighbor,  the  surgeon  resisting,  and  it  is  then 
forcibly  everted  again  by  the  surgeon,  the  patient  resisting. 

The  patient  now  lifts  the  arms  from  the  sides,  passing  perpendicularly 
to  the  floor  till  they  are  stretched  as  far  beyond  the  head  as  possible  and 
then  going  at  right  angles  to  the  trunk  and  parallel  with  the  floor,  returns 
them  to  sides  palms  up.  While  the  heels  are  held,  the  patient  rises  to  a 
sitting  position,  hands  at  the  sides;  then  she  rises  from  the  floor  with  the 
hands  behind  the  head  and  the  elbows  at  right  angles  to  the  trunk. 

The  patient  now  stands  with  the  heels  together;  toes  turned  slightly 
out,  hands  behind  the  head,  elbows  at  right  angles  to  the  trunk;  then 
rises  on  tip-toe,  bends  the  knees  and  hips,  keeping  the  back  as  straight 
and  erect  as  possible,  and  rises  up  once  more.  With  the  arm  on  the  con- 
cave side  high  above  the  head,  the  arm  on  the  convex  side  at  right  angles 
to  the  body,  she  rises  on  tip-toe,  bends  the  hips,  knees,  and  ankles  so  as 
to  squat,  then  rises  and  stands.  All  this  time  care  must  be  taken  to  push 
the  body  as  straight  as  possible,  and  gradually  educate  the  patient  to  hold 
it  so,  without  wiggling  during  these  movements. 

Let  the  patient  practise  walking  in  these  positions,  both  on  the  flat 
foot  and  tip-toe,  and  also  step  high  as  if  walking  up  stairs.  With  the 
palm  of  the  patient's  hand  on  the  convex  side  against  the  ribs,  pushing 
them  in,  with  the  hand  on  the  concave  side  she  pushes  a  slight  weight 
up  in  the  air  while  the  body  swings  so  as  to  straighten  out  the  curves. 

Sit  behind  the  patient,  fix  her  thighs  with  your  knees,  while  she  holds 
both  arms  above  the  head  and  bows  toward  the  floor,  keeping  her  knees 
stiff  while  you  keep  her  ribs  as  straight  as  possible  with  your  hands. 

With  the  arm  of  the  concave  side  across  the  top  of  the  head,  and  the 
arm  of  the  convex  side  around  in  front  of  the  abdomen,  the  patient  bends 
to  the  convex  side  through  the  ribs  and  not  through  the  waist. 

The  patient  sitting  with  the  back  toward  the  surgeon,  the  latter  pushes 
one  hand  against  the  most  prominent  part  of  the  convexity,  and  with  the 
other  hand  passed  around  the  shoulder  of  the  concave  side,  straightens 
out  the  curve  as  much  as  possible,  the  hand  on  the  "  bulge  "  acting  as  a 
fulcrum  in  straightening  the  curve. 

The  patient  sits  on  a  stool  in  front  of  the  surgeon,  who  fixes  the  pelvis 
with  his  knees.  The  patient  then  twists  the  projecting  shoulder  to  the 
front,  while  the  surgeon  holds  the  elbows,  which  are  at  right  angles  to 
the  trunk,  the  hands  being  behind  the  head,  and  makes  resistance.  In 
the  same  position  the  patient  swings  forward  and  back,  swinging  through 
the  hips,  keeping  the  back  stiff  and  not  bending  in  the  waist. 

The  patient  pushes  in  the  ribs  on  the  convex  side  with  the  hand,  and 
pushes  up  with  the  hand  on  the  concave  side,  the  same  as  when  stand- 
ing. She  also  lifts  the  arm  of  the  concave  side  at  right  angles  with  the 
body  while  holding  a  weight. 


LATERAL    CUKVATUKK    OF    THE    SPINE. 


129 


The  exercises  should  be  such  as  develop  the  muscles  of  the  back, 
including  the  neck;  the  glutei  muscles  and  others  about  the  hip  usually 
also  need  exercising,  and  the  abdominal  muscles  also  in  most;  cases. 

Suspension  as  a  means  of  muscular  exercise  is  in  all  probability  of 
little  value,  as  the  muscles  which  are  brought  into  play  are  chiefly  the 
arm  muscles.  The  temporary  relief  of  the  superincumbent  weight  which 
is"  afforded  by  suspension  may  correct  the  curve  in  a  measure,  but  the 
effect  cannot  be  lasting.  Suspension  will,  however,  help  to  relieve  for  a 
while,  in  some  severe  cases 
of  lateral  curvature,  the 
sense  of  discomfort  caused 
by  badly  distributed  weight 
falling  upon  a  distorted 
spine.  The  same  may  be 
said  of  trapeze  and  ring 
exercises. 

The  importance  of  mus- 
cular strength  in  main- 
taining the  erect  position 
suggests  the  development 
of  certain  muscles  as  a  ra- 
tional method  of  treatment. 
When  this  can  be  accom- 
plished, and  is  not  prevent- 
ed by  changes  in  the  shape 
of  the  bones  or  contraction 
of  the  ligaments  or  mus- 
cles, it  is  manifestly  bene- 
ficial. 

By  development  of  the 
strength  of  the  muscles  a 
correct  attitude  in  a  flex- 
ible spine  is  more  easily 
maintained. 

The  amount  of  exercise 
and  the  means    used  nec- 
essarily vary  with  the  patient.      Where  gymnasia  are  at  hand  the  various 
gymnastic  appliances  can  be  made  of  service- — but  efficient  treatment  can 
be  carried  out  by  the  persistent  use  of  simpler  means. 

Heavy  Gymnastics. — The  method  of  muscular  development  demon- 
strated by  Sandow  has  been  employed  with  advantage  in  cases  with  weak 
back  muscles.  This  has  been  thoroughly  carried  out  by  Teschner.  of 
New  York.1 


Fig.  121.— Paper  Jacket,  Hinged.    (Weigel.) 


1  Annals  of  Surgery,  August,  1805;  Orth.  Trans.,  vol.  ix. 


9 


130 


ORTHOPEDIC   SURGERY. 


For  success  the  patient  should  exercise  daily  with  dumbbells  weighing 
from  one-half  to  five  pounds,  and  three  times  a  week  exercises  under  super- 


Fig.  133.— Diagram  of  Plaster  Jacket. 


FIG.  133.— Slipping  of  Plaster  Jacket. 


vision  with  heavier  weights  should  be  taken.  The  weight  of  these  heavy 
bars  and  bells  and  the  amount  of  the  exercise  depend  upon  the  strength, 
capacity,  and  endurance  of  the  individual.  Each  patient  is  put  to  his  limit 
of  work  at  each  visit,  and  this  limit  is  extended  at  each  visit.  This  increase 
is  largely  dependent  on  correctness  of  posture  and  precision  in  the  work. 


Fig.  134.  Fig.  135. 

Figs.  124-136.— Beely's  Corset.    (Schreiber.) 


Fig.  13ti. 


The  bells  weigh  from  five  pounds  upward  each,  and  the  steel  bars  and 
bar-bells  twenty-six  pounds  and  upward.     The  exercises  are  as  follows : 

Bells  are  pushed  from  the  shoulders  above  the  head  alternately  as 
often  as  the  patient's   strength  permits.     The  patient  swings  a  heavy 


LATERAL   CURVATURE   OP   THE    SPINE.  131 

bell  with  one  hand  from  the  floor,  above  the  head  and  down  again,  the 
elbow  and  wrist  being  fixed  and  the  motion  repeated  as  often  as  possible 
in  a  systematic  manner;  then  with  the  other  hand  the  same  number  of 
times  and  later  with  both.  This  exerts  all  the  extensor  muscles  from  the 
toes  to  the  head  in  rapid  succession. 

When  a  heavy  ball  is  pushed  or  swung  above  the  head  on  the  side 
opposite  the  scoliosis,  the  action  of  the  back  muscles  is  such  as  to  cause 
the  curved  spine  to  approximate  a  straight  line.  A  similar  result  is  pro- 
duced when  a  heavy  weight  is  held  by  the  side  of  the  erect  body  on  the 
scoliotic  side,  the  arm  being  at  full  length. 

When  a  heavy  bar  is    raised  above   the  head  with   both  hands  the 
patient  must  fix  the  eyes  upon  the  middle  of  the  bar  to  maintain  the 
equilibrium.      This  necessitates  the  bending  of  the  head  backward,  the 
straightening    and    hyperextending  of 
the    spine,   and  consequently    correct- 
ing   a  faulty  position  with    a  weight 
superimposed.     The  heavier  the  weight 
put  above  the  head,  whether  with  one 
hand  or  with  two,  the  more  the  patient 
must  exert  himself  to  attain  and  main- 
tain  a  correct  or  an  improved  attitude 
in  order  to  sustain  the  equilibrium. 

■  When  a  patient  lying  supine  upon 
the    floor   raises  a   heavy   bar    above 

J  Fig.  137.— Seat    Elevated   on    One  Side  for 

the  head  so  that  the  arms  are  perpen-  changing  Lumbar  curves, 

dicular  to  the  floor,  the  weight  of  the 

bar,  the  position  and  weight  of  the  body,  and  the  action  of  the  mus- 
cles tend  to  broaden  the  entire  back  and  shoulders,  and  a  slow  downward 
movement  tends  to  widen  the  entire  chest,  and  most  markedly  the  shoul- 
ders. Pushing  the  bells  above  the  head,  swinging  them  with  each  hand 
and  with  both  hands  together,  raising  a  bar  above  the  head,  standing  and 
lying  down,  and  the  exercises  above  enumerated  constitute  a  day's  work. 

Whether  light  or  heavy  exercises  are  used,  persistence  is  necessary  for 
success. 

3.  To  Prevent  the  Spinal  Column  from  being  Held  Constantly  Out  of 
Line. 

Fixation  Appliance. — It  is  manifest  that  during  the  formative  period 
of  growth  faulty  attitudes  are  to  be  avoided.  Recumbency  being  inap- 
plicable for  a  long  period,  and  gymnastics  being  possible  only  for  a  limited 
portion  of  the  day,  some  form  of  appliance  which  checks  faulty  positions 
is  often  desirable. 

Corsets  made  of  plaster-of-Paris,  leather,  paper,  and  celluloid,  or  cloth 
stiffened  with  steel,  act  as  supports  and  limit  faulty  positions.  Weakening 
of  the  muscles  from  the  use  of  such  appliances  must  be  combated  by  sys- 


132 


ORTHOPEDIC    SURGERY. 


teniatic  gymnastics.  These  appliances  should  be  removable  if  designed 
simply  as  means  of  preventing  faulty  attitudes,  and  are  made  in  the  same 
way  as  removable  corsets  for  the  convalescent  stage  of  Pott's  disease,  ex- 
cept that  they  are  modelled  to  correct  certain  positions  and  not  to  fix  the 
spinal  column.  Such  attitudes  are  chiefly  as  follows :  the  dropping  of  one 
shoulder,  raising  the  other,  curving  and  twisting  the  spine  to  the  side. 

"When  side  inclination  of  the  trunk  exists  to  such  an  extent  as  to 
make  the  lumbar  curve  the  chief  curvature,  raising  the  pelvis  (by  placing 
an  increased  thickness  under  the  sole  of  the  shoe  on  the  apparently  lower 
hip,  and  a  pad  under  the  lower  buttock  in  sitting)  will  serve  as  partial 
correction. 

Corrective  Measures. — When  shortened  ligaments  in  spinal  curvatures 
are  situated  so  that  they  serve  as  a  strong  check  to  muscular  activity, 
purely  muscular  exercises  are  not  sufficient  for  corrective  stretching. 
Gymnastics,  therefore,  alone  are  inadequate  as  a  system  of  correction  in 
cases  of  this  class,  though  of  use  as  an  adjuvant  and  as  a  method  of  pre- 
vention of  relapse  after  correction.  It  has  been  proved  by  clinical  ex- 
perience and  by  experiments  on  cadavera  that  pressure  on  different  parts 
of  the  thorax,  i.e.,  on  the  ribs,  is  effective  in  correcting  torsion  of  the 
spinal  column.     This  may  be  employed  as  a  means  of  systematically  re- 


Fig.  128.— Recumbent  Pressure  Correction  Machine.    (Children's  Hospital  Report.) 


peated  correction  similar  to  that  used  by  those  training  themselves  as 
contortionists  or  dancers. 

The  arrangements  depicted  in  the  accompanying  illustrations,  which 
are  slightly  modified  from  the  appliances  described  by  Lorenz,  Beely,  and 
Weigel,  will  be  of  service  for  corrective  purposes.  Daily  use  of  these  will 
be  found  to  correct  distortions  which  simple  suspension  or  recumbency  will 
not  affect.  The  effect  of  such  correction  is  only  temporary,  unless  the 
gain  be  improved  upon  by  fixative  appliances  or  gymnastics. 


LATERAL   CURVATURE    OF    THE    SPINE. 


I 


If  the  spinal  column  is  arched  backward  moderate  rotation  can  be 
made  to  disappear,  and  if  slight  bony  or  ligamentous  change  prevents  the 
entire  disappearance  of  the  rotation,  force  can  be  applied  to  greater  me- 
chanical advantage  (by  means  of  appliances)  when  the  patient  is  reo - 

bent  or  the  weight  is  taken  off  of  the 
spinal  column  than  when  the  patient 
is  erect. 

The  corrective  treatment  of 
lateral  curvature  in  the  early  por- 
tion of  the  stage  of  development 
should  be  therefore  an  attempt  to 
increase  the  backward  flexibility  of 
the  spinal  column,  especially  in  that 
portion  where  the  curve  is  the  most 
pronounced. 

A  simple  appliance  for  home  use, 
which  should  be  placed  upon  a  flat 
lounge,  consists  of  a  board  a  little 
wider  than  the  patient  and  long 
enough  to  hold  the  greater  part  of 
the  patient's  trunk  when  recum- 
bent. At  the  end  of  the  board 
should  be  a  wooden  bar  covered  with 
a  padded  leather  pillow.  This  bar 
should  revolve  on  two  pivots  secured 
to  the  board,  and  the  patient  should 
lie  with  her  shoulders  upon  this 
padded  bar,  which  should  be  raised 
about  ten  inches  from  the  plane  of 

the     board.         An     assistant     should   FIG.  129.-Pressure  Correction  Machine.    (Children's 

Hospital  Report.) 

gently  pull  the  patient  so  that  the 

shoulders  will  project  beyond  this  roller,  and  should  then  direct  and  as- 
sist the  patient  to  raise  the  arms  above  the  head  and  bend  the  head  and 
arms  and  upper  portions  of  the  neck  and  back  as  far  backward  as  possible. 
The  patient  should  then  be  directed  to  take  deep  inspirations  and  expand 
the  chest  as  far  as  she  is  able ;  she  should  now  turn  so  as  to  lie  chiefly  upon 
the  projecting  shoulder,  the  assistant  pressing  upon  the  projecting  ribs  in 
front  and  the  patient  breathing  as  deeply  as  possible.  If  the  chief  curve 
is  in  the  lumbar  region,  the  lower  portion  of  the  back  should  be  placed 
upon  this  roller,  the  legs  held  down  by  an  assistant,  and  the  patient 
directed  to  bend  backward  as  far  as  she  conveniently  can. 

It  is  manifest  that  this  method  of  what  may  be  termed  intermittent 
correction  should  be  accompanied  by  gymnastics  and  corsets  or  appliances 
maintaining  correct  attitudes. 


134 


ORTHOPEDIC    SURGERY. 


la  certain  cases  the  curves  are  too  resistant  to  be  altered  materially 
by  intermittent  correction.  If  the  patient  is  still  at  a  period  of  growth, 
attempts  can  be  made  to  correct  the  curves  by  a  method  of  constant  press- 
ure, similar  in  principle  to  that  used  in  dentistry  to  alter  the  shape  of  the 
jaws.  For  the  application  of  this  method,  plaster  jackets  should  be  ap- 
plied to  the  patient  in  a  corrected  position. 

It  is  evident  that  this  method  of  correction  is  applicable  only  during 
the  growing  period,  and  it  is  also  true  that  to  be  efficient  the  correcting 
force  should  be  applied  constantly  and  not  intermittently. 

In  a  back  of  this  class  it  will  be  seen  that  there  are  three  points  for 
correcting  pressure  :  one  over  the  greatest  convexity  ;  the  second  point,  the 


Fig.  130.— Apparatus  for  Self-correction. 


Fig.  131. — Method  of  Self-correction. 


pelvis ;  and  the  third,  in  the  upper  portion  of  the  trunk  between  the  neck 
and  the  scapula  on  the  side  opposite  that  of  the  greatest  dorsal  projection. 
The  points  for  counter-pressure  in  front  are  diagonally  opposed  to  the  cor- 
responding points  in  the  back,  namely,  upon  the  pelvis,  upon  the  shoulder, 
and  upon  the  thorax.  It  is  found  necessary  also  to  arrange  that  the  droop- 
ing shoulder  should  be  supported  and  that  there  should  be  a  certain  amount 
of  lateral  correction  pressing  the  neck,  side,  and  the  pelvis  in  the  direc- 
tion of  correction.  These  points  necessarily  vary  in  different  cases,  but 
the  principle  that  correction  pressure  and  opposing  resistant  pressure  are 
needed  remains  the  same  in  all  cases  of  correction  in  lateral  curvature. 

No  anaesthetic  is  required,  and  no  pressure  is  used  which  is  beyond 
the  endurance  of  the  patient  without  marked  discomfort. 


LATERAL   CURVATURE   OF   THE    SPINE. 


1  35 


The  principle  of  this  method  of  correction  consists  of  utilizing  the 
dependent  weight  of  the  trunk  supported  by  plates  at  the  points  where 
correcting  pressure  in  the  back  is  desired.  This  is  accomplished  by  a 
method  similar  to  that  described  in  the  forcible  rectification  in  Pott's 
disease,  by  means  of  aluminum  plates  of  small  size  and  padded,  on  which 


Fig.  132. 


Fig.  133. 


^S& 


Fig.  134. 
Figs.  132-134.— Apparatus  for  Forcible  Correction  of  Scoliosis. 


the  patient  lies,  resting  upon  uprights  raised  or  lowered  by  a  screw  force 
at  will.  These  plates  support  the  trunk  from  falling  at  the  requisite 
points,  viz.,  the  pelvis,  the  dorsal  region  at  the  point  of  greatest  convex- 
ity, and  at  the  neck  in  the  region  of  compensating  convexity.  The 
uprights  are  secured  to  an  iron  frame  but  are  adjustable,  and  cross  straps 
support  the  head  and  thighs.     Plaster  bandages  are  applied  around  the 


136 


ORTHOPEDIC    SURGERY 


trunk  of  the  patient  in  this  position,  and  counter-pressure  is  exerted 
in  front  b}'  the  hand  or  by  straps  upon  the  projecting  shoulder  and  pro- 
truding hip  or  ribs.  Correction  of  lateral  deviation  can  be  furnished  by 
horizontal  traction,  if  necessary,  or  by  side  pressure.  Felt  padding  is 
needed  over  the  portions  of  the  body  which  are  but  little  protected  by 
fatty  tissue ;  the  plaster  bandages  should  be  applied  high  up  under  the 
drooping  shoulder  and  over  the  shoulder  from  behind,  across  the  neck. 
When  the  plaster  is  sufficiently  hardered  the  patient  can  be  lifted,  the 


Fig.  W>. — Correction  by  Pressure. 


detachable  aluminum  plates  which  are  thoroughly  padded  remaining  in 
the  jacket.  After  the  patient  is  placed  in  the  standing  position,  a  steel  rod 
can  be  incorporated  in  the  plaster  in  such  a  way  as  to  carry  a  strap  which 
passes  around  the  projecting  shoulder  and  draws  the  shoulder  backward, 
as  is  seen  in  the  accompanying  illustration  (Fig.  139).  Instead  of  the 
plaster  passing  over  the  neck,  a  broad  padded  strap  can  be  used,  arranged 
as  seen  in  the  accompanying  illustration.  This  is  lighter  and  more  cleanly 
than  the  plaster  bandage  applied  to  the  neck.  If  this  is  properly  ad- 
justed it  will  be  seen  that  the  plaster-of-Paris  jacket  does  not  tip  in  such 


LATERAL  CURVATURE  OF  TIIK  SI 'INK. 


137 


a  way  as  to  exert  a  pressure  upon  the  hollow  portion  of  the  back,  as  is 
frequently  the  case  if  the  plaster  jacket  is  applied  in  the  ordinary  way, 


Fig.  136.— Points  for  Pressure. 

as  has  been  shown  by  Bernard  Roth  and  others.  This  does  not  necessitate 
the  use  of  perineal  straps  to  prevent  twisting  or  tipping  of  the  jacket, 
but  it  enables  it  to  exert  the  pressure  upon  the  chest  only  in  the  portions 
where  pressure  is  desired.  It  will  be  found  that  a  removable  jacket  is 
not  so  efficacious  as  a  permanent  one,  as  it  is  impossible  to  exert  the  pres- 
sure as  efficiently  after  the  jacket  is  removed.     After  as  much  correction 


Fig.  137.— Frame  for  Forcible  Correction. 

as  is  possible  has  been  obtained,  a  removable  jacket  of  stiffened  leather 
or  celluloid  can  be  used,  accompanied  by  gymnastics. 

This  method  will  be  found  to  be  efficient  in  altering  the  shape  of  a 
distorted  trunk,  diminishing  and  correcting  both  the  rotation  and  side 
twist  in  growing  children. 


138 


ORTHOPEDIC   SURGERY. 


When  the  bones  have  become  hardened  by  growth,  correction  is   not 
possible  either  by  intermittent  or  permanent  pressure.     The  treatment 

must  be  palliative  and  consist  of  gymnas- 
tics, massage,  or  electricity  to  relieve 
symptoms,  accompanied  or  not,  according 
to  circumstances,  by  corsets  as  a  partial 
support  to  superimposed  weight. 

Operative  attempts  consisting  of  re- 
section of  the  projecting  ribs,  although 
performed  by  Yolkmann  and  Hoffa  in  a 
few  instances,  have  not  yet  been  accepted 
as  among  the  recognized  methods  of  prac- 
tice in  orthopedic  surgery. 

Choice    of    Methods. 

If  the  methods  of  treatment  mentioned 
be  recapitulated,  they  may  be  summarized 
as  follows:  1,  recumbency;  2,  postural; 
3,  gymnastic;  4,  fixation;  5,  correction. 
These  are  severally  suited  to  different 
classes  of  cases,  and  the  selection  of  the  proper  method  or  methods  will 
vary  according  to  the  patient' s  condition  and  the  state  of  the  curvature. 


Fig.  138.— Detail  of  Pad  Plate  in  Frame. 


IV&V  w.,    ■  ,{V 

\  \   v     '  ■  "' 

Fig.  139. — Corrective  Jacket  (Front). 


Fig.  14(1.— Corrective  Jacket  (Back). 


LATERAL   CURVATURE   OF   THE   SPINE. 


139 


If  the  back  is  flexible  and  no  osseous  change  has  taken  place ;  if  the  cur- 
vature entirely  disappears  when  the  patient  is  recumbent  or  suspended, 
and  is  apparently  dependent  upon  habits  of  attitude,  standing,  or  sitting, 
the  postural  method  is  applicable,  coupled  with  careful  selection  of  school 
seats,  desks,  and  home  chairs. 

If  to  this  condition  of  habitual  faulty  attitudes  weakness  of  certain 
groups  of  muscles  is  added,  proper  gymnastics  should  be  employed.  Jf 
a  short  leg  is  present  it  should  be  corrected. 

If  the  curves  are  threatening  to  increase,  and  the  patient  gives  evi- 
dence of    exhaustion,    recumbency  for    several  hours  a  day   should  be 


Fig.  141.— Lateral  Curvature  before  Cor- 
rection. 


Fig.  142.— Lateral  Curvature  Three  Weeks 
after  Correction. 


enforced;  and  in  the  worse  cases,  recumbency  should  be  aided  by  fixation 
in  improved  position  by  means  of  appliances.  Of  appliances,  removable 
plaster  jackets,  or  corsets  of  that  type,  will  be  found  the  most  available, 
as  they  are  of  service  in  preventing  or  checking  the  assumption  of  faulty 
attitudes,  and  as  checks  to  torsion  and  growing  out  of  the  ribs. 

Appliances,  however,  should  always  be  regarded  as  supplementary 
to  gymnastic  treatment,  and  should  be  used  only  temporarily  during  the 
period  of  the  greatest  increase  of  the  curves. 

When  the  curves  are  somewhat  fixed,  but  some  flexibility  still 
remains,  the  method  of  correction,  either  intermittent  or  constant,  car- 


140  ORTHOPEDIC    SURGERY. 

ried  out  for  several  months  will  be  found  helpful,  in  addition  to  gymnas- 
tics and  postural  exercises. 

Corsets  and  mechanical  appliances  necessarily  weaken  the  muscles  of 
the  back,  and  are  to  be  avoided  if  possible,  and  when  they  are  used,  mas- 
sage is  advisable  in  addition  to  gymnastics. 

In  the  severest  types  of  rigid  curves,  no  corrective  treatment  is  advis- 
able, as  the  symptoms  can  be  relieved  by  stiff  corsets,  or  suspension, 
recumbency,  massage,  and  electricity. 

The  length  of  time  needed  for  treatment  varies  necessarily.  In  gen- 
eral it  should  be  stated  that  growing  children  with  a  tendency  to  faulty 
attitude  need  careful  inspection  during  the  years  of  growth.  The  inspec- 
tion need  not  be  frequent,  and  will  vary  from  three  months  to  six  months 
according  to  the  rate  of  growth.  In  light  cases,  a  few  weeks'  super- 
vision of  gymnastics,  followed  by  monthly  or  quarterly  inspection,  is  all 
that  is  necessary.  In  more  threatening  cases,  frequent  methodical  correc- 
tion and  the  use  of  appliances  under  supervision  for  several  months  are 
desirable. 


CHAPTER  III. 

OTHER    AFFECTIONS    OF    THE    SPINE. 

Curvatures  of  the  spine. — Kyphosis. — Lordosis. — Spondylitis  deformans. — Osteo- 
myelitis.-—  Typhoid  spine.  — Traumatic  spondylitis.  —  Malignant  disease.— 
Syphilis. — Spondylolisthesis. — Sprains  of  the  spine. — Hysterical  spine. — Dis- 
tortion of  the  thorax. 

At  birth  the  spinal  column  is  straight  and  does  not  present  the  physi- 
ological curves  constant  in  later  life. 

Physiological  curves  begin  as  soon  as  the  child  attempts  to  sit  and 
stand.  The  cervical  and  lumbar  regions  curve  forward  and  the  dorsal 
region  curves  backward.  The  cervical  curve  differs  from  the  others  in 
that  it  can  be  obliterated  by  a  change  in  the  position  of  the  head,  while 
the  other  curves  are  after  early  childhood,  in  part  at  least,  permanent. 

These  curves  vary  according  to  the  habits,  occupation,  muscular  sys- 
tem, sex,  and  figure  of  the  individual.  The  normal  curves  are  forward  in 
the  cervical  region,  backward  in  the  dorsal,  and  forward  in  the  lumbar. 

The  limits  of  movement  in  the  spine  are  set  by  the  shape  of  the  ver- 
tebrae, the  length  of  the  ligaments,  and  the  tonicity  of  the  muscles. 

Muscles  weakened  by  disease,  by  overuse,  by  too  rapid  growth,  or 
from  any  cause,  which  are  unable  thoroughly  to  do  the  work  expected 
of  them,  do  not  prevent  an  increase  of  these  curves.  The  spine  is  longer 
in  recumbency  than  in  the  erect  position.  The  amount  of  this  change 
will  be  seen  by  referring  to  the  accompanying  table  of  measurements  of 
the  height  of  eleven  people  standing,  and  their  length  when  lying  upon 
the  floor  on  their  backs ;  ten  of  these  were  adults  and  one  was  a  child. 
The  difference  was  relatively  greatest  in  the  child. 


Number. 

Age. 

Height  in  Erect 
Position. 

Length  in  Dorsal 
Recumbency. 

Difference. 

1 

2 

28 
40 

38 
15 
22 
29 
30 
22 
31 
35 
3^ 

5  ft.     8£    in. 
5  "        -s-   " 

°                     16 

5  "      8 

5  "      8|f   " 

5  "    11H   " 

5  "    11&   " 

G  "      2 

5  "      4||   " 

Q     11            1     S          11 

°              116 

5  ft.     9i    in. 

6  "      2TV    " 
5  "      8,V   " 
5  "      1TV   " 
5  "      8J£   " 

5  "      9       " 

6  "        T-V   « 

5  "    llif   " 

6  "        ^l!    " 

"16 

5  "      5-^   " 
3  "      2T\   " 

if  in. 
ii    " 

16" 

7       " 
"16 

14      " 
TS 
10      " 
T6 

4        " 

3 

4 

5 

6 

7 

6        l' 
TS 

4       i< 
TS 
1  2      " 
TS 

8       <« 
T6" 
1  2      " 

8 

9 

10 

11 

Result  same  in  eight  other  cases  in  which  measurements  were  not  recorded. 


142 


ORTHOPEDIC    SURGERY. 


When  the  variations  of  the  normal  curves  become  exaggerated  they 
may  be  regarded  as  abnormal  and  are  classed  as  (1)  curvature  with  con- 
vexity backward — kyphosis;  (2)  curvature  with  convexity  forward — lor- 
dosis. 

Kyphosis. 

This  curve  is  more  common  in  the  upper  than  in  the  lower  part  of  the 
spinal  column,  and  inay  be  observed  after  Pott's  disease,  in  spondylitis 
deformans  (rheumatoid  vertebral  ostitis),  after  processes  by  which  the 
structure  of  the  bone  tissue  is  weakened  or  altered  (such  as  osteomalacia, 
rickets,  ostitis  deformans,  and  malignant  disease  of  the  spinal  column), 
or  changed  by  a  constantly  assumed  bent  attitude,  or  when  the  muscles 
of  the  back  are  weakened  or  paralyzed. 

Round  Shoulders. — The  term  round  shoulders  is  generally  applied 
to  the  stooping  attitude  resulting  from  faulty  growth,  or  habitual  atti- 
tude occasioned  by  occupation.  The  attitude  is  well  known  and  famil- 
iar.    The  head  is  not  carried  erect  but  run  forward  somewhat,  the  shoul- 


Fig.  143.— 3ide  View  of  Case  of  Round  Shoulders. 


Fig.  144.— Contraction  of  Chest  from  Forward 
Drooping  of  the  Shoulders. 


ders  slope  forward,  the  scapulae  are  unduly  prominent  behind,  and  the 
chest  appears  narrow  and  flat;  in  addition  the  lumbar  spine  is  at  times 
curved  forward  so  that  the  patient  stands  with  an  unduly  hollow  back; 
at  other  times  the  curve  of  the  lumbar  spine  does  not  differ  from  normal. 
The  deformity  is  common   among   rapidly  growing  children,   especially 


OTHER   AFFECTIONS   OF   THE    SPINE. 


1 1:; 


girls,  in  whom  the  skeleton  has  grown  more  rapidly  than  the  muscles.  Al- 
though the  faulty  attitude  may  be  corrected,  it  will  be  again  assumed,  ow- 
ing to  a  lack  of  strength  of  the  muscles  to  maintain  the  corrected  position. 
In  some  instances  shorten- 
ing of  the  ligaments  exists, 
holding  the  spine  and  ribs 
in  a  distorted  position. 
Occasionally  the  arms  are 
held  forward,  and  if  an  at- 
tempt is  made  to  bring  the 
uplifted  arms  to  a  vertical 
position,  this  can  be  done 
only  by  arching  the  spine 
forward  in  the  lumbar  re- 
gion, owing  to  contraction 
of  the  muscles  and  liga- 
ments in  the  front  of  the 
chest. 

A  common  etiological 
factor  in  these  cases  is  the 
stooping  attitude  assumed 
by  school  children  sitting 
for  many  hours  of  the  day 
in  positions  which  stretch 
without  developing  the 
muscles  of  the  back.  The 
attitude  may  be  and  fre- 
cpuently  is  favored  by  cloth- 
ing, the  weight  of  which  is 
thrown  by  shoulder  straps 
upon  the  shoulders,  and  in 
many  instances  to  this  is 
added  the  pull  of  side 
stocking  supporters,  fast- 
ened tightly  to  a  waist  with  the  shoulder  straps,  so  that  the  child's 
shoulders  are  strapped  forward. 

Occupation. — An  increase  in  the  dorsal  curve  is  noticed  in  certain 
occupations.  Tailors,  who  sit  cross-legged  with  the  spine  bent,  and  cob- 
blers, who  bend  over  their  work,  are  two  classical  examples  of  this  type 
of  curvature.  A  curve  from  a  similar  cause  is  seen  in  school  children 
who  bend  over  their  work,  sitting  at  desks  of  improper  height  and  in 
chairs  of  improper  construction ;  it  is  not  unfair  to  class  this  as  kyphosis 
of  occupation. 

Old  Age. — A  marked  form  of  kyphosis  is  seen  in  the  round  shoulders 


Fig.  145.— Photograph  Showing  Depression  in  the  Outline  vt 
the  Shoulder  from  Shoulder  Straps. 


U± 


ORTHOPEDIC   SURGERY. 


common  in  old  age,  when,  with  the  general  wasting  of  the  tissues,  absorp- 
tion of  the  intervertebral  discs  takes  place  and  the  vertebral  column 
assumes  a  greater  curve  than  normal  in  the  dorsal  region. 

Osteomalacia.- — A  rare  form  of  kyphosis  is  seen  in  osteomalacia,  in 
which  the  whole  spine  may  be  bent  so  that  it  forms  one  long  arch  with  the 


/"/''  rM 


FlCx.  146. 


FIG.  147. 


FIG.  148. 


Fig.  146.— Attitude  of  Child ;  Projecting  Abdomen,  Hollowing  in  the  Back  and  Bending  Neck  For- 
ward.   The  skirts,  buttoned  on  the  waist,  exert  a  forward  pull  on  the  shoulders. 

Fig.  147.— In  Raising  the  Arms  the  Back  is  Bent  Forward  in  the  Lower  Dorsal  Region. 

FIG.  148.— The  Exostoses  Occurring  in  Senile  Kyphosis.    Antero-posterior  section.    (After  Beneke.) 


convexity  backward.     In  one  severe  case  examined  by  one  of  the  writers 
the  curve  was  so  great  that  the  chin  rested  on  the  umbilicus. 

Ostitis  Deformans. — In  this  condition  a  kyphosis  is  characteristic. 
There  is  commonly  a  bowing  forward  in  the  spine  more  prominent  in  the 
cervical  and  upper  dorsal  regions,  while  the  lumbar  region  loses  its  con- 
cavity and  becomes  straighter  than  normal,  the  head  drops  toward  the 
chest,  the  shoulders  are  round  and  stooping.  The  spine  may  be  rigid 
and  painful ;  there  may  also  be  scoliosis  in  this  condition.  The  body  is 
shortened  in  the  erect  position  by  the  curvature  and  the  walk  is  with  the 
trunk  bent  forward.  The  attitude  resembles  that  in  spondylitis  defor- 
mans, but  it  must  be  remembered  that  in  ostitis  deformans  the  joints  are 
as  a  rule  exempt  and  that  it  is  a  chronic  inflammatory  disease,  most 
often  of  advanced  life,  affecting,  besides  the  spine,  the  long  bones,  the 
cranium,  and  the  pelvis.     It  is  characterized  by  pain,  hypertrophy,  and 


OTHER    AFFECTIONS    OF    THE    K  1*1. ML 


145 


softening  of  the  bones  so  that  the  bones  which  sustain  weight  become 
curved.1 

Rickets. — A  backward  bending  of  the  spine  which  involves  generally 
the  lumbar  as  well  as  the  dorsal  spine,  occurs  often  in  young  children 
with  acute  rickets.  In  this  condition  the  whole  spine  is  convex  backward 
and  the  point  of  greatest  curve,  which  at  times  appears  angular,  is  at  the 
junction  of  the  lumbar  and  dorsal  regions.  It  is  often  difficult  to  diagnos- 
ticate from  Pott's  disease,  and  one  must  depend  upon  the  general  symp- 
toms of  rickets  to  establish  the  diagnosis.     At  times  the  prominence  dis- 


FlG.  149. 


FIG.  150. 


Fig.  151. 


Fig.  149.— Ostitis  Deformans.    (Lunn.) 

Fig.  151.— Femur  in  Ostitis  Deformans.    (Humphrey.) 


Fig.  150.— Ostitis  Deformans.    (Hutchinson.) 


appears  upon  laying  the  child  on  the  face  and  hyperextending  the  spine, 
but  at  other  times  the  spine  is  stiff  and  unyielding  as  in  Pott's  disease. 


'Paget:  Med.  Ch.  Trans.,  1877,  37,  lx.  ;  idem,  Med.  Ch.  Trans.,  lxv.,  1882,  225; 
idem,  Tr.  Path.  Soc,  xxxvi.,  1884,  382;  Stilling:  Virch.  Arch.,  vol.  119,  542;  Pie: 
Rev.  de  Chir.,  1897,  169;  Taylor:  Tr.  Am.  Orth.  Assn.  ;  Thibierge :  Arch.  Gen.de 
MM.,  January,  1890,  p.  52  (excellent  bibliography);  Paget:  111.  Med.  News.  1889, 
181  ;  Edmunds  :  111.  Med.  News,  1889  ;  Lunn  :  111.  Med.  News,  1889  ;  Robinson  et.  al.  : 
111.  Med.  News,  1889 ;  Watson:  Johns  Hopkins  Bulletin,  1898,  ix.,  133  ;  Fielder: 
Trans.  Path.  Soc,  1896,  47,  190. 
10 


146 


ORTHOPEDIC   SURGERY. 


The  treatment  consists  in  recumbency  on  the  back  during  the  active 
period  of  rickets,  and  on  assuming  the  erect  position  some  form  of  steel 
antero-superior  support  for  the  spine  may  be  needed.     Poorly  nourished 
infants  with  weak  muscles  often  sit  in 
a  position  resembling  this  deformity  of 
rickets,  but  the'  back  is  perfectly  flex- 
ible   and    correction    occurs    on     lying 
down. 

Paralysis.- — A  very  marked  bend- 
ing backward  of  the  whole  spine, 
generally  with  obliteration  of  the  lum- 
bar curve,  is  sometimes  seen  with  par- 
alysis of  the  back  muscles,  either 
after  anterior  poliomyelitis  and  simi- 
lar affections  of  the  muscles,  or  in  the 


FIG.  152.— Skull  in  Ostitis  Deformans.    (Mansell-Moul- 

lin.) 


Fig.  153.— Kyphosis   in  Advanced  Paralysis 
of  the  Back  Muscles. 


advanced  stages  of  pseudo-muscular  hypertrophy,  progressive  muscular 
atrophy,  or  syringomyelia.  In  these  cases  the  patient  sits  with  the  head 
resting  almost  on  the  knees,  the  whole  back  forming  one  curve  with  the 
convexity  backward. 

In  acromegaly  kyphosis  may  exist  with  consolidation  of  several  of  the 
vertebrae.1     Kyphosis  may  also  exist  in  pulmonary  osteo-arthropathy. 


Lordosis. 

Lordosis  is  the  name  applied  to  the  increase  of  the  physiological  curve 
forward  in  the  lumbar  region.  This  exists  in  various  abnormal  condi- 
tions, and  the  amount  of  curve,  of  course,  varies  in  normal  individuals 
from  those  who  have  very  flat  backs  in  the  lumbar  region  to  those  who 
have  a  very  markedly  hollow  back.  In  certain  cases  in  which  the  indi- 
vidual is  perfectly  normal  a  very  marked  lumbar  curve  exists.  It  is 
hardly  necessary  to  do  more  than  mention  the  various  conditions  in  which 
lordosis  exists. 

1.  Lordosis  often  exists  in  connection  with  the  kyphosis  of  the  dorsal 


•Osborne:  Trans.  Assn.  Am.  Physicians,  vol.  xii.,  p.  271. 


OTHER   AFFECTIONS    OF    THE    SPINE. 


m 


spine  spoken  of  in  connection  with  round  shoulders;  here  it  is  compensa- 
tory to  the  dorsal  curve  and  the  result  of  muscular  weakness. 

2.  Lordosis  also  exists  in  pregnant  women  and  often  in  persons  with 
large  abdomens,  due  to  accumulation  of  fat  or  to  distention,  such  as  as- 
cites and  abdominal  tumors.  In  these  cases  it  is  simply  the  balancing 
of  weight  in  which  the  centre  of  gravity  is  brought  over  the  centre  of  sup- 
port. 

3.  Increased  lumbar  curve  also  exists  as  the  result  of  training  in  pro- 
fessional gymnasts,  especially  in  backward  contortionists.  Such  persons 
habitually  walk  with  a  marked  degree  of  lordosis. 

4.  In  conditions  in  which  the  abdominal  or  the  back  muscles  are 
paralyzed  the  attitude  of  lordosis  is  the  result  of  an  attempt  to  balance 
the  weight  of  the  upper  part  of  the  body  without  bringing  a  strain  upon 
the  muscles.     In  paralysis  of  the  abdominal  muscles  lordosis  exists. 

5.  In  Pott's  disease  of  the  lumbar  region  apparent  lordosis  may  be 
one  of  the  first  symptoms  to  be  noticed. 

6.  In  cases  of  double  congenital  dislocation  of  the  hip  lordosis  gener- 
ally exists,  because  the  point  of  support  of  the  femur  on  the  pelvis  is 
oftenest  back  of  the  acetabulum, 

consequently  the  pelvis  rotates 
on  a  transverse  axis,  carrying  the 
lumbar  spine  forward.. 

7.  Lordosis  exists  in  many 
cases  of  severe  rickets  on  ac- 
count of  the  rotation  of  the  pel- 
vis on  a  transverse  axis,  as  will 
be  described  in  speaking  of 
rickets. 

8.  In  hip  disease,  in  which 
on  account  of  a  muscular  rigidity 
or  adhesions  one  leg  is  flexed 
upon  the  pelvis  in  the  position 
of  flexion  of  the  leg,  the  pelvis 
rotates  on  a  transverse  axis  and 
the  lumbar  spine  is  carried 
forward.  In  that  way  the  pa- 
tient is  able  to  stand  or  lie  with 
the  legs  in  the  same  plane.  As 
recovery  from  hip  disease  with 
the  leg  slightly  flexed  is  not  un- 
usual, nor  altogether  undesirable  if  ankylosis  must  be  present,  this  form 
of  lordosis  is  fairly  common.  In  double  hip  disease  with  flexion  deform- 
ity the  lordosis  may  be  extensive.  Contraction  of  the  hip,  for  any  reason, 
as  in  infantile  paralysis,  causes  lordosis. 


154.— Tempered    Steel    Uprights    for    Round 
Shoulders. 


148  ORTHOPEDIC    SURGERY. 

9.  Lordosis  may  exist  in  coxa  vara,  both  secondary  to  the  distortion 
at  the  hip  and  as  another  manifestation  of  the  rhachitic  change. 

10.  In  spondylolisthesis  lordosis  is  very  marked. 

Treatment. — The  treatment  of  these  curves  is  necessarily  dependent 
npon  the  causative  conditions  and  attendant  circumstances.  In  rapidly 
growing  children  it  is  desirable  to  correct  faulty  attitudes  in  sitting  too 
long  at  school  studies  without  a  change  of  position,  and  to  remove  con- 
stricting clothing.  The  chief  treatment  will  be  gymnastic  directed  in 
part  to  the  development  of  the  strength  of  the  back  muscles.  The  ex- 
ercises described  for  lateral  curvature  can  be  adapted  for  round  shoulders 
and  holloAv  back. 

Occasionally  appliances  are  needed  to  maintain  proper  attitudes,  but 
these  are  to  be  avoided  if  possible  and  reserved  for  exceptional  cases. 

The  same  can  be  said  of  recumbent  treatment,  which  is  to  be  only 
occasionally  employed,  although  a  daily  rest  in  the  recumbent  position  is 
advisable  in  the  case  of  rapidly  growing  and  muscularly  weak  children  of 
this  type. 

Spondylitis  Deformans. 

Spondylitis  deformans  is  a  condition  characterized  chiefly  by  an 
ankylosing  affection  of  the  spine  with  more  or  less  involvement  of  other 
joints.  The  pathological  process  is  in  a  general  way  similar  to  that  seen 
in  rheumatoid  arthritis,  or,  as  it  may  be  called,  arthritis  deformans,  and 
most  authorities'  do  not  separate  the  two  conditions,  except  that  in  spon- 
dylitis deformans  the  affection  generally  first  attracts  attention  in  the 
spine.  Marie2  would  separate  the  condition  from  arthritis  deformans  in 
general  on  the  ground  that  the  former  attacks  the  spine,  shoulders,  and 
hips  while  the  joints  of  the  extremities  may  remain  free.  He  describes 
six  cases  (three  of  them  personal  observations)  and  names  the  condition 
spondylose  rhizomelique. 

Spondylitis  deformans  is  also  called  spondylosthesis  deformans,  anky- 
losis of  the  spine,  rheumatism  of  the  spine,  arthritie  deformante  du 
rachis,  and  Verwachsung  oder  Steifigkeit  der  Wirbelsaule. 3  It  occurs  in 
children,  but  most  often  in  young  male  adults,  and  in  many  cases  is  pre- 
ceded by  a  history  of  gonorrhoea.  In  a  case,  however,  reported  by  Marie 
(a  gonorrhoeal  inflammation  of  the  spine),  the  cervical  region  was  the  one 


1  Ziegler  :  "Path.  Anat.,"  Sec.  i.-viii.,  English  edition,  p.  273. 

2  Revue  de  Mea.,  April,  1898,  p.  285. 

3Bechterew.  Deutsche  Zeit.  f.  Nervenheilk.,  1897,  xi.  327;  Beer:  Wiener  med. 
Blatter,  1897,  xx.,  127;  Bradford:  Ann.  Anat.  and  Surg.,  1883;  Hutchinson:  Arch. 
Surg.,  1896,  vii.,  246;  Oppenheim  :  "Lehrbuch  der  Nervenkr.";  Ziegler:  "Path. 
Anat,"  Bd.  ii.,  228;  Beneke :  Festschr.  f.  LXIX.  Versamml.  deutsch.  Naturf.  u. 
Aerzte,  1897,  p.  109;  Marie:  Rev.  de  med.,  1898.  p.  288. 


OTHKK   AFFECTIONS    OF   THE    SPINE. 


1  t9 


chiefly  affected  and  the  involvement  progressed  downward.     The  affection 
in  other  respects  was  similar  to  that  to  be  described. 

The  pathological  process  must  be  judged  from  museum  specimens  and 
is  not  to  be  distinguished  from  that  in  arthritis  deformans,  except  that 
ossification  of  the  fibrous  perivertebral  structures  and  even  fusion  of  osteo- 
phytes seems  to  be  the  chief  feature,  rather  than  any  great  amount  of 
change  in  the  joint  surfaces.  Specimen  09  in  the  Musee  Dupuytren  shows 
this,  and  is  characterized  by  ossification  of  the  prevertebral  and  spinous 
ligaments.  Periosteal  proliferation  is  apt  to  be 
] narked,  and  the  vertebrae  are  united  to  each 
other  by  osseous  bridges  (Ziegler). 

The  apparently  primary  involvement  of  the 
spine  is  in  marked  contrast  to  the  ordinary 
distribution  of  rheumatoid  arthritis. 

There  is,  however,  another  class  of  cases  prob- 
abty,  as  to  which  we  have  no  pathological  data,  in 
which  the  muscles  and  soft  parts  are  implicated. 

Pasteur     reported 

one    such   case  in 

1889,    in    which 

scleroderma  seem- 
ed to  play  a  part, 

and    Beer     points 

out  the  similarity 

of  this  to  the  more 

usual    cases.     For 

certain     cases     of 

his    own     he    as- 
sumes    a     change 

in  the  soft  parts, 
whether  vaguely  related  to  scleroderma  or  not,  as  primary,  and  is  in- 
clined to  blame  "  Muskelschwielen  "  as  at  least  part  cause.     The  results 
of  massage  and  electricity  which  he  reports  certainly  lend  probability  to 
this  view.1 

The  affection  is  clearly  a  primary  ankylosing  arthritis  of  the  vertebral 
column,  accompanied  by  manifestations  of  a  disease  which  resembles 
rheumatoid  arthritis. 

Adams,'  in  his  classical  monograph  on  rheumatic  gout,  mentions  spi- 
nal rheumatism  as  occurring  in  severe  cases  affecting  other  joints,  the 
distortion  sometimes  being  so  severe  as  to  interfere  with  locomotion. 


Fig.  155.— Ankylosis  of  Vertebrae, 
Articular  Processes  Primarily  Affected  .; 
Absorption  of  Vertebral  Bodies.  (Speci- 
men in  Warren  Museum.) 


Fig.  156.— Ankylosis  of  the 
Spine.  (Specimen  in  Warren 
Museum.) 


1  "Rheumatisme  Blennorrhagique  "  (N.  Diet,  de  Med.  et  Ckir.,  Blemiorrkagie). 
Nolen:  Deutsches  Archiv  f.  klin.  Med.,  No.  8,  1882,  p.  120.  Ferron:  These  de 
Paris,  1868,  No.  211. 

2  Annals  of  Anatomy  and  Surgery,  Brooklyn,  1883.  vol.  vii.,  p.  6. 


150  ORTHOPEDIC    SURGERY. 

The  deformities  of  the  vertebral  column  following  spondylitis  defor- 
mans may  sometimes  exercise  compression  upon  the  nerve  roots. 

Pain  in  the  spine  is  present  in  an  acute  or  chronic  form,  sometimes 
aggravated  by  every  jar  and  paroxysmal  in  character.  In  other  cases 
pain  may  be  a  subordinate  symptom,  and  may  be  little  complained  of. 
Stiffness  of  the  spine  is  the  characteristic  symptom.  The  lumbar  curve 
is  obliterated  while  the  dorsal  curve  is  increased,  and  the  patient  walks 
more  or  less  bent  over  by  the  dorsal  kyphosis,  with  a  gait  somewhat  like 
that  of  Pott's  disease.  In  stooping  the  motion  is  entirely  from  the  hips. 
In  lying  down  the  curves  are  not  affected  or  obliterated.  The  lower 
spine  is  said  to  be  first  affected  and  the  cervical  last.  In  the  severest 
cases  the  spine  is  stiff  from  the  sacrum  to  the  occiput,  and  permits  no 
more  motion  than  would  an  iron  rod.  In  the  severer  cases  the  ribs  are 
ankylosed  at  their  junction  with  the  spine,  and  the  chest  wall  scarcely 
moves  in  inspiration,  or  it  may  be  entirely  stationary  and  the  breathing  is 
wholly  abdominal.  As  the  cervical  vertebrae  are  usually  the  last  to  be 
affected,  motion  of  the  head  may  be  possible  after  the  dorsal  and  lumbar 
regions  have  become  rigid.  In  less  severe  cases  the  spine  is  not  involved 
to  the  whole  extent,  but  marked  stiffness  without  angular  projection  exists 
in  a  portion  of  the  column.  Stiffening  and  flexion  of  the  hips  is  com- 
mon, and  leads  to  a  most  distressing  gait  in  which  the  whole  body  is  car- 
ried bent  forward.  Some  stiffness  of  the  shoulders  is  generally  an  early 
symptom. 

The  course  of  the  disease  is  chronic  in  the  extreme,  and  its  duration 
covers  many  years.  The  bone  inflammation  has  no  destructive  tendency 
and  accomplishes  nothing  more  than  stiffening  the  vertebral  column.  The 
impairment  of  the  general  health  consequent  upon  this  is  generally  not  so 
severe  as  one  would  anticipate. 

The  diagnosis  of  the  affection  can  be  made  by  recognizing  the  rigidity 
of  the  entire  vertebral  column  without  the  angular  prominence  of  Pott's 
disease,  nor  does  the  latter  affection  so  stiffen  the  whole  column,  but  only 
the  diseased  region.  Pott's  disease  involving  the  whole  or  a  large  por- 
tion of  the  vertebral  column  would  soon  lead  to  very  marked  results  in 
its  destructive  tendency.  The  immobility  of  the  ribs  is  a  pathognomonic 
sign  of  the  affection,  and  the  involvement  of  other  joints  would  merely 
confirm  one's  opinion  of  the  character  of  the  disease.  The  early  stages 
of  the  affection  have  never  been  seen  by  the  writers  and  have  not  been 
satisfactorily  described. 2 

1  Pain  may  be  at  times  due  to  compression  of  the  nerve  root  (Oppenheim). 

2  Braun  •  "Klin,  und  Anat.  Beitrage  z.  Kenntniss  d.  Spondylitis  Deformans,-" 
Transactions  of  the  London  Clinical  Society,  1879,  p.  204;  Rosenthal:  "Diseases 
of  the  Nervous  System,"  American  translation,  1879,  p.  225,  Putzel :  "Functional 
Nervous  Diseases,"  p.  133;  Brodhurst:  Reynolds' "System  of  Medicine,"  vol.  i., 
9(30;  Delpech-  "L'Orthomorphie." 


OTHER   AFFECTIONS   OF   THE   SI'INE.  151 

It  need  hardly  be  said  that  the  prognosis  is  unfavorable.  The  harm 
done  is  irremediable  and  the  prospect  of  checking  the  disease  almost  hope- 
less. The  dorsal  curvature  will  probably  increase,  and  if  the  other  joints 
are  involved,  the  patient's  condition  is  deplorable. 

Treatment. — In  the  matter  of  treatment  very  little  can  be  said.  The 
general  measures  useful  in  rheumatoid  arthritis  ordinarily  should  be 
faithfully  tried.  The  outlook  in  this  affection  is  no  better  than  in  the 
other  manifestations  of  these  diseases.  Electricity  to  the  spine  and  mas- 
sage may  be  of  soma  use  in  altering  conditions  of  the  local  circulation. 
It  is  useless  to  try  to  ward  off  the  approaching  ankylosis  by  manipulation, 
and  the  measure  is  harmful  and  painful.  Hot  applications  and  hot 
baths  sometimes  mitigate  the  symptoms. 

When  pain  is  present  on  motion,  mechanical  support  is  indicated. 

An  acute  form  of  rheumatic  inflammation  of  the  vertebral  articulations 
has  been  mentioned,  but  such  a  form  is  rare. 

Acute  spinal  symptoms  may  exist  in  connection  with  gonorrhoea,  oc- 
curring as  described  by  Finger, '  and  characterized  by  girdle  pains,  in- 
creased reflexes,  tenderness  and  muscular  spasm  of  the  spine,  parsesthesia 
of  the  legs,  and  similar  symptoms. 


Acute   Osteomyelitis  of    the    Sptxe. 

This  condition  may  affect  either  the  anterior  or  posterior  part  of  the 
vertebral  column ;  it  is  of  the  same  general  character  as  acute  osteom}-e- 
litis  occurring  elsewhere.  It  may  occur  as  the  result  of  trauma,  as  secon- 
dary to  suppuration  elsewhere,  or  as  a  condition  apparently  primary. 
Four-fifths  of  all  cases  recorded  have  occurred  in  adolescents.  The  infec- 
tion is  caused  by  the  streptococcus  or  the  staphylococcus  pyogenes  aureus. 
The  lumbar  spine  is  most  often  affected. 

The  condition  is  charaterized  by  rapid  onset,  high  fever,  and  great 
constitutional  disturbance.  Abscess  occurs  early,  and  the  tissues  surround- 
ing the  abscess  are  cedematous.  Abscesses  may  occur  from  the  transverse 
processes  and  extend  both  forward  and  backward.     Posterior  abscesses  are 

dinger:  "Blennorrhcea,"  p.  338,  quoting  Myrtle,  Striimpell,  Fournier,  Hayem, 
and  Parmentier;  Marie:  Rev.  tie  M^d.,  April  10th,  1898;  Vulpius  :  Monatsch.  f.  Un- 
fallhk.,  1897,  iv.,  201 ;  Beer  :  Wien.  med.  Blatter,  1897,  xx.,  127  ;  Bechterew  :  Deutsch. 
Zeitsch.  f.  Nervenhk.,  1897,  xi.,327;  Stocker:  Clin.  Journ.,  London,  May  9th,  1894 
(ref.  Schmidt) ;  Miles :  Lancet,  November,  189-1 ;  Striimpell :  Deutsche  Zeitschr.  f. 
Nervenheilk,  1897,  xi.,  338  ;  Oppenheim  :  "  Lehrbuch  der  Nervenkrankheiten,"  1894.  S. 
210;  Roberts:  Phila.  Med.  Times,  1885,  p.  209;  Osier:  "Pract.  of  Med.,"  p.  403; 
Henle  :  Deutsche  med.  Wochenschr.,  1894,  Vereinsbeilage,  S.  20  ;  Pasteur  :  Clin  Soc. 
Trans.,  vol.  xxii.  ;  Goldthwait:  Orth.  Trans.,  vol.  xii.  ;  Muttener :  Deutsch. 
Zeitschr.  f.  Kinderheilk.,  1898,  xiv.,  144  ;  Thayer:  Phila.  Med.  Journ.,  1898.  ii..  95-5 
(with  account  of  twenty  autopsies). 


152  ORTHOPEDIC   SURGERY. 

accessible  for  operation ;  anterior  abscesses  are  almost  impossible  to  locate. 
Abscess  occurs  in  practically  all  cases.  Paralysis  was  present  in  one- 
third  of  the  recorded  cases.  Secondary  centres  of  suppuration  are  likely 
to  occur  in  other  parts  of  the  body.  Deformity  of  the  spine  is  not  of  very 
frequent  occurrence.  It  must  be  remembered  that  although  the  process 
is  rapidly  destructive  the  formation  of  new  bone  is  equally  rapid,  and  that 
the  severity  of  the  disease  necessitates  the  recumbent  position  during  the 
acute  stage. 

The  mortality  has  been  said  to  be  as  high  as  sixty  per  cent,  but  this 
cannot  be  accepted  as  accurate  as  the  less  severe  forms  of  the  affection 
may  often  have  been  overlooked. 

Direct  incision  to  the  bone  furnishing  drainage  is  indicated  as  soon 
as  is  possible.  During  convalescence  the  spine  should  be  supported  as  in 
Pott's  disease.1 

Typhoid  Spins:. 

The  term  "typhoid"  spine  was  applied  by  G-ibney  to  a  condition 
of  the  spine  simulating  Pott's  disease,  except  in  the  matter  of  deformity, 
which  occurs  occasionally  after  typhoid  fever.  It  was  thought  by  Gibney 
to  be  due  to  an  inflammation  of  the  structures  surrounding  the  vertebrae 
(perispondylitis).  In  the  cases  described  by  Gibney  excessive  pain  and 
stiffness  of  the  back  were  present  and  at  times  sensitiveness.  His  cases 
made  good  progress  with  one  exception,  in  which  a  slight  impairment  of 
the  gait  persisted. 

The  affection  is  to  be  regarded  as  of  the  class  of  infectious  bone  proc- 
esses following  typhoid,  as  described  by  Keen,  Park,  and  others. 

Quincke  reported  two  cases,  both  of  which  recovered.2 

Traumatic   Spondylitis. 

Under  this  name  Kummell  described,  in  1891,  an  affection  of  the  ver- 
tebral column  following  injury,  resembling  Pott's  disease  most  closely, 
but  assumed  to  be  of  a  non-tuberculous  character.  Very  few  autopsies 
have  been  brought  forward  as  demonstrating  the  non-tubercular  character 
of  the  affection.3 

The  kyphus  is  said  to  be  generally  larger  and  more  rounded  than  in 

'Miiller:  Deutsche  Zeitschr.  f.  Chir.,  xli.  ;  Halm :  Beitrage  zur  klin.  Chir., 
xlv.,  Hft.  1;  Makins  and  Abbott:  Ann.  Surg.,  May,  1896;  Chipault :  Gaz.  desH6p., 
1897,  lxx.,  1442  ;  Riese  :  Centralbl.  f.  Chir.,  1898,  S.  585  ;  Tixier  :  Le  Bulletin  meU, 
July  21st,  1895. 

■  Quincke:  Mitth.  aus  den  Grenzgeb.  der  Med.  und  der  Chir.,  1898,  iv.,  244; 
Gibney  :  Orth.  Trans.,  vol.  ii.  and  iv. ;  Osier  :  Johns  Hopkins  Hospital  Reports,  iv.,  80. 

3Staffel :  Monatschft.  f.  Unfallhk.,  1897  ;  Chipault:  "L'Apophysalgie  Pottique," 
Travaux  de  Nenrologie  Chir.,  1898. 


OTHER   AFFECTIONS   OF   THE   SPINE.  I  '-■ 

tuberculosis,  and  there  is  said  to  be  generally  a  long  interval  between 
the  injury  and  the  symptoms.  It  is  said  that  abscesses  do  not  occur 
(Hettemer).  Partial  paralysis  has  been  present  in  many  of  the  cases  de- 
scribed. 

It  is  obvious  that  after  the  fracture  of  the  spine  a  kyphus  may  exist. 
If  the  patient  is  allowed  to  go  about  before  the  callus  has  become  firm, 
this  kyphus  may  increase.  Konig  held  that  all  cases  were  limited  to 
this.  Kilmmell  believed  that  a  rarefying  ostitis  was  the  cause  of  trau- 
matic spondylitis;  Henle  assumed  an  osteoporosis  or  a  process  analogous 
to  osteomalacia,  and  speaks  of  the  possibility  of  a  trophic  and  vasomotor 
disturbance  due  to  lesions  of  the  central  nervous  system.  Wagner  and 
Stolper1  speak  of  the  mechanical  shutting  up  of  damaged  vertebral  bodies 
when  subjected  to  increased  pressure. 

As  this  affection,  as  described,  is  considered  a  destructive  ostitis  of  the 
vertebrae,  following  an  injury  after  a  long  interval,  it  is  a  question  if  it 
deserves  the  separate  classification  given  to  it,  differing  so  little  as  it  does 
from  the  usual  course  of  caries  of  the  spine  in  symptoms  and  treatment.3 

Malignant    Disease    of    the    Spine. 

Sarcoma  and  carcinoma  of  the  vertebral  column  are  occasionally  met. 
Sarcoma  may  be  either  primary  in  this  location  or  secondary  to  some 
deposit  elsewhere.     Carcinoma  is  probably  secondary  always. 

Sarcoma  in  several  reported  autopsies  has  been  found  to  be  of  the 
large-celled  type.  Michel a  has  described  these  under  the  head  of  "  tumor 
myeloides."  Cysts  or  cavities,  with  fluid  or  semi-fluid  contents,  are  fre- 
quently found,  and  he  has  suggested  a  relation  between  this  and  hydatid 
cysts,  but  this  can  hardly  be  sustained.  Carcinoma  has  been  noted  fol- 
lowing similar  disease  of  the  breast  and  testicle,  and  less  frequently  of  the 
stomach.  The  occurrence  may  be  from  direct  extension,  or  from  general 
infection. 

The  disease  usually  begins  as  an  infiltration  of  the  spongy  tissue  of 
the  vertebral  bodies,  which  is  gradually  replaced  by  the  malignant 
growth.  There  may  be  but  little  change  in  the  appearance  of  the  bodies, 
but  these  will  be  found  converted  into  a  soft,  friable  mass.  Destruction 
of  the  bone  substance  with  deformity  may  occur.      Small  growths  exter- 

1  Deutsche  Chirurgie,  Lief,  xl.,  p.  244. 

2 Hettemer:  Beitr.  z.  klin.  Chir. ,  xx.,  p.  103  (with  full  bibliography)  ;  Kir- 
misson  :  Rev.  de  Chir.,  1896,  481  ;  Kocher;  Mitth.  aus  den  Grenzgeb.  der  Med.  u.  d. 
Chir.,  1895-06,  p.  448;  Henle:  Ibid.,  1896-96,  Hit.  3 ;  Heidenham  .  Monatschr.  f. 
Unfallheilkunde,  iv. ,  3,  65;  Schneller :  Munch,  nied.  Wochenschr. ,  xliv.,  p.  2,  Vul- 
pius:  Monatsch.  f.  Unfallheilkunde,  iv.  7,  201  ;  Kirsch:  Ibid.,  iv.,  5,  140;  Bahr : 
Aerztlicher  Praktiker,  1897,  No.  17. 

3"Nouv.  Diet,  de  MeU  et  de  Chir.,''  39,  222. 


154 


ORTHOPEDIC   SURGERY. 


nal  to  the  vertebrae  are  sometimes  seen,  and  are  likely  to  be  mistaken  for 
malignant  disease  of  the  vertebral  column. 

The  most  frequent  site  of  malignant  disease  is  in  the  lumbar  region, 
and  the  next  commonest  location  is  in  the  dorsal  vertebras  (Amidon). 

The  disease  may  pursue  an  insidious  course,  and  not  be  suspected 
until  found  at  the  autopsy.  This,  however,  is  rare,  and  a  serious  affec- 
tion is  usually  evident,  even  though  no  diagnosis  is  made.  The  chief 
symptoms  are  pain  and  paralysis,  and  both  are  the  result  of  the  encroach- 
ment of  the  growth  on  the  spinal  nerves  and  cord.  Considering  the 
course  of  the  former  and  the  intimate  relation  to  the  diseased  bone,  it  is 
not  surprising  that  pain  should  be  an  early  and  prominent  symptom.  It 
is  usually  increased  by  pressure  and  motion.  The  location  of  the  pain 
will  depend  on  the  site  of  the  diseased  vertebrae,  and  will  be  accordingly 


FIG.  157.— Sarcoma  of  Spine. 

in  the  arms,  trunk,  or  legs.  Edes1  states  this  symptom  may  disappear 
more  or  less  completely  at  a  later  period.  The  paralysis  usually  follows 
a  disturbance  in  sensation  and  is  due  to  compression  from  extension  of 
the  disease,  or  from  involvement  of  the  meninges.  It  may  be  partial  or 
complete,  and  as  a  rule  does  not  occur  suddenly.  The  occurrence  of  oedema 
from  thrombosis  in  paralysis  rather  favors  the  theory  of  this  disease  as 
the  cause. 

Tenderness  over  the  spine  is  an  uncertain  sign,  and  probably  has  no 
more  diagnostic  importance  than  in  ordinary  spinal  caries.  It  was  noted 
as  present  in  seven  of  Amidon' s  twenty -four  cases.      When  deformity 


1  Edes:  Bost.  Med.  and  Surg.  Jour.,  June  17th,  1880,  559. 


OTHER   AFFECTIONS   OF   THE   SPINE.  155 

occurs  it  will  be  found  to  present  a  more  rounded  prominence  than  is 
usually  seen  in  Pott's  disease.  Hemorrhage  from  the  bowels  or  hema- 
turia has  been  observed. 

Charcot '  gave  the  name  of  "  paraplegia  dolorosa  "  to  the  condition 
which  he  had  observed  to  follow  infiltration  of  the  vertebrae,  more  par- 
ticularly those  cases  seen  by  him  after  cancer  of  the  breast,  which  re- 
vealed the  existence  of  this  disease,  which  was  otherwise  latent.  These 
symptoms  consist  of  pain,  chiefly  in  the  lumbar  region,  and  radiating 
through  the  lower  limbs.  In  character  these  pains  are  lancinating.  There 
is  formication,  sense  of  constriction  about  the  waist,  no  anaesthesia,  but 
on  the  other  hand  there  is  frequently  hyperaesthesia.  Walking  is  usually 
interfered  with,  but  complete  paralysis  does  not  occur.  The  bladder  and 
rectum  are  not  affected,  and  there  is  a  marked  vasomotor  disturbance, 
as  shown  by  the  tendency  to  rapid  formation  of  bedsores,  etc. 

When  following  malignant  disease  elsewhere,  which  can  be  recog- 
nized, the  diagnosis  should  present  no  special  difficulty,  but  in  other 
instances  is  usually  hard  or  even  impossible.  It  should  be  distin- 
guished from  aneurism  of  the  aorta,  cervical  pachymeningitis,  and  Pott's 
disease. 

The  prognosis  needs  no  comment,  a  fatal  end  is  only  a  matter  of  time.2 

Syphilis    of   the   Vertebrae. 

Syphilitic  destruction  of  the  bodies  of  the  vertebrae  must  be  considered 
as  possible  and  not  unlikely,  but  the  recorded  cases  of  this  sort  are  not  in 
general  satisfactory  as  proving  pathologically  that  such  a  condition  has 
existed.  The  presence  of  syphilis  in  a  patient  with  a  knuckle  in  the  back 
does  not  prove  that  tuberculosis  is  absent  or  that  the  vertebral  destruction 
is  of  a  syphilitic  character. 

The  best  authenticated  cases  are  as  follows :  Jitrgens,  a  case  in  which 
at  autopsy  syphilis  of  the  cervical  vertebrae  was  found.  Paralysis  had  ex- 
isted during  life.  Lewin,  a  case  of  gumma  of  the  axis ;  Konig,  a  case 
of  syphilitic  granulations  of  the  spinous  processes. 

The  occurrence  of  gummata  of  the  vertebrae  or  near  them  in  such  posi- 
tion as  to  cause  pressure  on  the  cord  must  be  admitted,  also  the  syphilitic 
origin  of  certain  vertebral  exostoses.  Gowers  cites  a  case  of  syphilitic 
caries  of  the  spine,  but  it  was  secondary  to  pharyngeal  ulceration. 

The  diagnosis  of  syphilitic  spondylitis  in  most  cases  has  rested  on  the 
slenderest  clinical  evidence,  which  cannot  be  accepted  (cases  of  Jasinski, 
Kidlon,  Staub,  Lewot,  Leyden,  etc.).     Under  these  circumstances  nothing 

1  Charcot :  Cornptes  rendus  de  la  Soc.  de  Biol.,  1865,  28. 

8  v.  Bechterew :  Neurol.  Centrabl.,  1893,  313;  Foderl  und  Peharn :  Deutsch. 
Zeitsch.  f.  Chir.,  xlv.  ;  Dennis:  "System  of  Surgery;"  Amidon :  N.  Y.  Med.  Jour., 
1887,  225;  Edes:  Boston  Med.  and  Surg.  Jour.,  1886,  civ.,  559. 


156  ORTHOPEDIC   SURGERY. 

can  be  said  of  the  clinical  course  of  the  affection.     The  writers  are  unable 
to  report  personal  cases. ' 

Spondylolisthesis. 

The  name  -spondylolisthesis  (tT-6vduAo$,  a  vertebra,  and  'ofa<rdrjtrisf  a 
gliding)  refers  to  a  forward  subluxation  of  the  body  of  one  of  the  lower 
lumbar  vertebrae,  with  the  exception  of  one  recorded  case  in  which  the 
upper  part  of  the  sacrum  was  displaced  forward.  This  displacement  has 
ordinarily  been  described  as  a  dislocation ;  in  most  instances  it  hardly 
reaches  a  greater  degree  than  may  be  described  by  the  name  subluxation. 
Even  this  name  is  incorrect  anatomically,  because  the  body  of  the  verte- 
brae is  chiefly  affected,  while  the  laminae  and  spinous  process  remain  prac- 
tically in  place. 

Fr.  !N eugebauer, a  of  Warsaw,  has  thoroughly  investigated  and  elabo- 
rated the  subject.  In  1854,  this  condition  was  recognized  and  named  by 
Killian.3  Blake,4  Gibney, 5  Lombard6  and  Lovett 7  have  contributed 
American  observations. 

Pathology. — The  pathological  condition  is  fairly  constant,  degree 
and  location  varying  within  certain  limits.  The  essential  part  of  the 
condition  seems  to  be  the  slipping  forward  of  one  of  the  lower  lumbar 
vertebral  bodies,  while  the  vertebral  arches  remain  practically  in  place. 
This  implies,  of  course,  an  increase  in  the  distance  between  the  body  and 
the  spinous  process  of  such  a  vertebra. 

The  commonest  form  of  the  displacement  is  subluxation  of  the  fifth 
lumbar  vertebra  in  relation  to  the  sacrum.  The  displacement  of  the 
fourth  lumbar  vertebra  in  relation  to  the  fifth  is  next  in  frequency. 
The  displacement  forward  of  the  first  sacral  vertebra  in  relation  to  the 
rest  of  the  sacrum  has  been  recorded  once  only  (H.  von  Meyer,  Zurich 
specimen). 

The  displacement  may  be  slight  or  extreme.  Secondary  changes 
occur  in  the  severer  cases.  Exostoses  may  develop  about  the  joints  of  the 
displaced  vertebrae,  apparently  elongating  them,  and  the  intervertebral 

1  Staub  :  Wien.  nied.  Presse,  1896,  xxxvii.,  1468;  Jasinski :  Archiv  f.  Derm, 
u.  Syph.,  1891,  p.  409;  Lomikowsky :  Ibid.,  1879,  p.  334;  Oppenheini:  "Lehrb. 
der  Nervenkr. ,"  1894,  p.  209;  Leyden  :  Berliner  klin.  Wochenschr.,  1889,  p.  461; 
Pournier  :  La  Semaine  nied.,  1899,  p.  53  ;  Gowers  :  "New  Dis.,"  2d  ed.,  p.  261 ;  Rid- 
lon:  Orth.  Trans.,  iv.,  118. 

2  Neugebauer :  "Spondylolisthesis  et  Spondylizeine."  Paris,  G.  Steinheil,  1892. 
Critical  review,  description  of  specimens  and  cases,  complete  bibliography. 

3  Killian  :  "Comment,  anat.de  S.,"Bonn,  1853;  "Schilderung  neuer  Beckenfor- 
men,  Mannheim,  1854. 

4 Blake:  American  Journal  of  the  Medical  Sciences,  1867,  cvii.,  p.  285. 

5  V.  P.  Gibney  :  Medical  Record.  March  30th,  1889. 

6  Lombard  :  Boston  Medical  and  Sui'gical  Journal,  August  20th,  1885. 
'Trans.  Amer.  Orth.  Assn.,  1897. 


OTHER   AFFECTIONS   OF   THE   SPINE. 


157 


joints  may  be  obliterated  or  the  fibro-cartilage  may  be  replaced  by  an 
arthrodial  joint.  The  bony  arch  connecting  the  vertebral  bodies  and  the 
laminae  maybe  either  thinned  and  intact,  or  it  may  be  separated  entirely. 


F'G.  158.— Small  Pelvis  of  Prague  (Median  Section 
Instance  of  slight  forward  displacement  of  fifth  lum 
bar  vertebra.    (Neugebauer.) 


FIG.  159.—  Breslau  Specimen.  In- 
stance of  slight  forward  displacement 
of  the  fourth  lumbar  vertebra.  (Neuge- 
bauer.) 

This  may  be  a  unilateral  or  bi- 
lateral condition. 

The  causes  of  separation  of 
the  anterior  and  posterior  parts 
of  the  lumbar  vertebrge  are  clas- 
sified by  Neugebauer,   and  gen- 
erally accepted  to  be  as  follows : 
Separation   of   the   vertebral 
arch  due  to  congenital  defect.1 
Separation  of  the  vertebral  arch  due  to  fracture. 
Disease  of  the  sacro- vertebral  articulation. 
Bony  changes  the  result  of  pressure. 

Other  theories  as  to  etiology  may  be  dismissed 2  as  being  unsupported 
by  pathological  evidence. 

Spondylolisthesis  is  recorded  as  affecting  women  more  frequently  than 
men,  and  comparatively  few  male  cases  have  been  recorded.     It  occurs 


Fig.  160.— Pelvis  of  Moscow  (Median  Section).  In- 
stance of  extreme  forward  displacement  of  fifth  lum- 
bar vertebra.    (Neugebauer.) 


1  Broca:  Bull,  de  la  Soc.  d'Anat.  de  Paris,  1884,  p.  448.   * 

2Zeitsch.  f.  Heilk.,  1892;  Lambl :  Cent.  f.  Gyn.,  1881,  xi..  p.  25;  xii.,  p.  28; 
1885,  xxiii.,  p.  35(3;  Virchow's  Archiv,  1857,  xi.,  2,  187;  Bohu  :  Inaug.  Diss., 
Berlin,  1892;  "A  New  Case  of  Spondylolisthesis,  with  Successful  Delivery  ; "  Ols- 
hausen:  (a)  Mon.  f.  Geb.  u.  Gyn.,  1861,  Bd.  xvii.,p.  255;  (6)  Mon.  f.  Geb.  u.  Gyn., 
1864,  Bd.  xviii.,  p.  190. 


158 


ORTHOPEDIC   SURGERY. 


almost  always  at  puberty  or  in  young  adult  life,  and  the  majority  of 
all  cases  give  the  account  of  a  severe  traumatism,  occurring  most  often 
during  childhood  or  near  puberty.  The  deformity  may  follow  immedi- 
ately upon  the  accident,  or  it  may  develop  in  after  years,  just  after 
puberty  of  during  pregnancy.     Other  cases  are  to  be  accounted  for  only 


Fig.  161.— Spondylolisthesis  due  to  Vertebral  Disease.    (Dr.  H.  B.  Cushing,  Johns  Hopkin^HospitaL) 

by  frequency  of  pregnancy  or  by  very  hard  work.     In  some  cases  no  as- 
signable cause  can  be  found. 

The  symptoms  by  which  the  diagnosis  must  be  made  are  as  follows : 
A  disturbance  of  equilibrium  resulting  in  a  faulty  carriage,  which  is 
shown  chiefly  by  a  sharp  increase  in  the  lower  lumbar  curve  in  even  the 
mildest  cases.     More  exactly  it  seems  to  be  a  prominence  of  the  iliac 

crests  and  buttocks  in  relation  to  the  lumbar 
spine.  There  is  no  apparent  falling  away  of 
one  spinous  process  from  another,  for  rea- 
sons that  have  been  demonstrated  in  speak- 
ing of  the  pathology.  The  spine  curves  for- 
ward sharply  from  the  sacrum,  and  this  gives 
uudue  backward  prominence  to  the  crest  of 
the  ilium  and  the  buttocks.  The  appearance 
at  first  glance  is  the  same  as  that  in  cases 
of  double  congenital  dislocation  of  the  hip. 
Lateral  deviation  of  the  spine  may  be  pres- 
ent. With  this  lordosis  goes  a  diminution 
of  the  obliquity  of  the  pelvis,  which  rotates  on  its  transverse ;  axis  the 
pubis  is  higher  than  it  should  be  normally,  while  the  sacrum  is  lower. 
The  combination  of  lordosis  with  diminished  pelvic  obliquity  is  said  to  be 


Fig.  162.— Specimen  from  the  Mu- 
seum of  Kolliker  at  Wurzburg,  Show- 
ing Double  Defect  of  VerteBfral  Arch 
(Neugebauer.) 


OTHER   AFFECTIONS   OF   THE   SPINE. 


159 


pathognomonic  by  Neugebauer.  The  rotation  of  the  pelvis  is  an  impor- 
tant factor  in  that  it  tightens  the  anterior  ligaments  of  the  hip,  and  thus 
tends  to  cause  a  flexed  position  of  the  thighs. 

Vaginal  examination  shows,  of  course,  a  prominence  high  up  on  the 
posterior  wall  of  the  pelvis.  The  trunk  is  shortened  in  relation  to  the 
legs  on  inspection,  and  the  thorax  tends  to  approach  the  pelvis.  The 
gait  in  spondylolisthesis  is  said  by  Neugebauer  to  be  modified.  The  affec- 
tion is  not  one  characterized  by  excessive  pain. 

The  differential  diagnosis  must  be  made  from  Pott's  disease,  double 


■  Flt  m--C*set  of  SPondylolistbe-       Fig.  164. -Side  View  of  Case  of    Fig.  165.-Back  View  of  Same 
sis.  Woman, thirty  years  old.  (Brei-    Spondylolisthesis.     (Braunv.  ca se 

Sky-J  Fernwald.) 

congenital  dislocation  of  the  hip,  and  rickets.     Rickets  must  be  recog- 
nized by  its  general  diagnostic  signs. 

Treatment.—  From  the  few  cases  considered,  from  a  surgical  aspect 
the  most  successful  treatment  consists  in  fixation  of  the  lower  spine  by  a 
jacket  or  brace  until  the  fracture,  if  such  has  occurred,  has  united  and 
the  products  of  the  injury  have  been  absorbed}  or,  if  heavy  weight-bear- 
ing has  been  the  cause,  until  the  stretched  and  weakened  tissues  have 
resumed  as  normal  a  position  as  possible.  This  period  must,  of  course, 
last  for  months,  or  in  cases  of  great  deformity  it  would  seem  as  if  a  fixa- 
tion support  must  be  permanent.  Laminectomy,  as  demonstrated  by  the 
case  of  Mr.  Lane,  is  an  operation  to  be  considered  when  symptoms  of 
bony  pressure  are  present  for  any  length  of  time.  In  Gibney's  case  an 
unsuccessful  attempt  was  made  to  reduce  the  deformity  under  ether 


160 


ORTHOPEDIC   SURGERY. 


Recent  Literature. 


Lambl:  Prager   Vierteljahrschrift,  1850,  55-61;     Cent.    f.   Gyn.,   1881,  No.  11, 
p.  251 ;  No.  12,  p.  281 ;  1885,  No.  23,  p.  356  ;  M6decine  russe,  1859,  Nos.  11,  12,  16. 
Krukenburg:  Archiv  f.  Gyn.,  xxv.,  Heft  1. 
Meyer:  Archly  i.  Gyn.,  xxxi.,  Heft  1. 
Breslauer  arztl.  Ztschft.,  1882,  3  and  4. 
Winckel :  "Lehrbnch  der  Geburtshilfe,"  pp.  468-470. 

Czaussoirw  :  "  Anat.  top.  du  bassin,"  Warsaw,  1888,  pp.  10-15  (in  Russian). 
W.  A.  Lane:  Transactions  of  the  Pathological  Society  of  London,  1885,  xxxvi., 
p.  364;  Guy's  Hospital  Reports,  xliii.  ;  Lancet,  1893, 
xxix. ,  p.  991. 

Herrgott :  Annales  de  Gyn.,  May,  1883. 
Pirnig:    Woman,  aged   twenty-eight    years;    no 
history  of  fall.     Berl.  klin.  Woch.,  1887,  xxiii.,  509. 

Hertzfeld  :  Woman,  aged  twenty-five  years  ;  fall 
in  sixth  year.     Allg.  med.  Zeit.,  1892,  xxxvii. 

Lane  :  Woman,  aged  thirty -five  years ;  associ- 
ated with  progressive  paraplegia.  Laminectomy  for 
relief  of  pressure  of  cauda  equina.  Lancet,  1893, 
xxix.,  p.  991  ;  also  April,  1892,  No.  358. 

R^camier :  Man;  between  fourth  and  fifth  lum- 
bar vertebrae  as  a  result  of  spondyloschisis  ;  found  in 
dissecting-room.  Bull,  de  la  Soc.  d'Anat.,  1888,  p. 
914. 

Braun  von  Pernwald :  One  case,  woman,  aged 
thirty-six  years ;  occurred  under  hard  work.  The 
most  carefully  recorded  and  illustrated  of  any  case. 
Archiv  f.  Gyn.,  1896,  lii.,  p.  8. 

Schleiser:  Ein  Fall  von  S.  Becken.  Inaugural 
Dissertation,  Halle,  1890.  There  is  said  to  have 
been  a  case  reported  by  Herff.  v.  Braun,  Cent.  f. 
Gyn.,  1891,  xxviii.,  603.     No  details.     Woman. 

Bonn  :  Woman,  aged  twenty-five  years  ;  fall  when 
twenty-one  years  old.  Inaugural  Dissertation,  Ber- 
lin, 1892. 

Piskadek  :  Woman,  aged  thirty-nine  years  ;  prob- 
ably ossification  defect  in  fifth  lumbar  vertebra. 
Cent.  f.  Gyn.,  1889,  xlviii.,  p.  83. 

Dollinger  :  Child,  three  years  old.  who  fell  back- 
ward in  a  room,  and   paralysis   came   on.     Lordosis 
was  marked,    apparently,    but    the   column  could  be 
felt  to  have  fallen   forward    from    the    sacrum    and 
could  be  pushed  forward.     Cent.  f.  Chir.,  1891,  xxiii..  p.  457. 

Bennett:  Two  preparations.     Lancet,  July  20th,  1889,  p.  116. 
Frank:  Woman  ;  no  details.     Cent.  f.  Gyn.,  1892,  xviii.,p.  343. 
Targett:    Girl,   sixteen   years  old;    ordinary   life;    no  hard  work    or    trauma. 
Died  of  tetanus  ;  specimen.     Obstetrical  Transactions,  1891. 

Zoll :  Traumatic  case.     Preparation  of  pelvis.     Handbch.  der  gyn.  Gesellsch.  in 
Krakau,  1891,  ii.  p.  47. 

Roth:    Man,   seventeen  years   old;    fall    in     jumping;    increasing  deformity. 
Posterior  spinal  support  with  immediate  relief.     Chir.  Society  of  London,  1891. 


Fir;.  166.  -Traumatic  Spondyl- 
olisthesis in  a  Young  Man  of 
Eighteen. 


OTHER   AFFECTIONS   OF   THE    SPINE.  161 

Chiari :  Pelvis;  £orty-two-year-old  person,  with  exostoses.  Pelvis;  thirty- 
two-year-old  woman  ;  fall  at  fourteen ;  and  two  other  preparations.  Zeitsch.  f. 
Heilk.,  1892. 

Buchheister:  Geschichte  der  Aet.  der  Sp.  Inaugural  Dissertation,  Strassburg, 
1894  (a  review  containing  no  new  eases  and  nothing  of  especial  interest). 

Jellinghaus:  Arch.  f.  Gyn.,  1896,  p.  428. 

Vedeler:  Norsk.  Mag.  f.  Lag.,  Kristiania,  1896,  I  ):.,  xi.,  p.  833. 

Bieganski  :  Medycyna,  1890,  No.  22  (en  polonais). 

Billroth:  Archiv  f.  klin.  Chirurgie,  1896,  Bd.  x.,  p.  42. 

Blasius:  Mon.  f.  Geb.,  18G8,  Bd.  xxxxi.,  pp.  241-248. 

Leisrinck:  Langenbeck's  Archiv  f.  klin.  Chirurgie,  187^,  p.  <;:j. 

v.  Tliaden  :  Archiv  f.  klin.  Chirurgie,  Bd.  xviii.,  \).  4f>J. 

Sprains  of  the  vertebral  column  occur  at  times  after  falls.  Stiffness 
and  pain  may  reach  a  considerable  degree  and  render  the  diagnosis  from 
Pott's  disease  impossible  for  a  time.  In  the  cervical  region  wry -neck- 
may  be  present  from  muscular  spasm.  The  pain  maybe  very  severe. 
This  condition  of  sprain  may  persist  for  months,  and  in  neurasthenic  per- 
sons may  merge  into  the  so-called  hysterical  spine. 

Actinomycosis  of  the'  spine  has  been  recorded  with  partial  destruction 
of  four  vertebrae,  abscess,  and  pressure  symptoms.  Death  occurred  in 
eighteen  months.1 

Echinococcus1  cysts  of  the  spine  have  also  been  observed. 

Hysterical  Spine. 

This  condition  is  also  described  under  the  names  of  irritable  spine, 
sensitive  spine,  spinal  irritation,  a  functional  affection  of  the  spine,  weak- 
ness of  the  spine,  neuromimesis,  etc.  The  affection  may  occur  sponta- 
neously or  most  often  as  the  result  of  some  trauma,  either  mild  or  severe. 
It  appears  as  a  sensitive  and  painful  condition  of  the  spine,  manifested 
by  sensitiveness  most  often  over  the  spinous  processes  of  the  vertebras, 
pain  in  motion  and  manipulation;  and  in  most  of  the  cases  is  associated 
with  a  certain  amount  of  general  neurasthenia. 

Pain  and  tenderness  are  frequently  found  at  the  base  of  the  neck, 
between  the  shoulders,  in  the  lower  dorsal  region,  or  at  the  end  of  the 
spine.  This  pain  is  usually  subacute,  it  is  aggravated  by  fatigue,  and  it 
may  be  accompanied  by  much  hyperalgesia,  which  is  usually  localized  in 
a  comparatively  small  area  where  there  is  a  complaint  of  a  burning  sensa- 
tion, while  no  curvature  or  projection  can  be  seen  on  inspection  of  the 
back.  In  the  extreme  cases,  patients  are  unable  to  bear  any  weight  upon 
the  spine  in  sitting  or  standing,  and  they  present  the  symptoms  that  sug- 
gest a  hyperesthesia  of  the  ligaments  or  of  the  f asciee  of  the  back  muscles. 
Ordinarily  the  patients  are  able  to  go  about  freely,  but  suffer  great  pain, 

1  Henck:  Miinchener  med.  Wochensch.,  1892,  p.  512. 
*Friedberg:  Schmidt's  Jahrb.,  1897;  Bruns'  Beitr.,  xi.,  1894. 


162 


ORTHOPEDIC   SURGERY. 


especially  when  their  attention  is  turned  tu  the  subject  of  themselves.     In 
a  few  instances  of  the  severest  sort  the  back  is  held  stiffly,  and  any  con-1 
scions  attempt  at  bending  is  avoided  by  the  patient ;   but  unconsciously, 
when  the  patient's  attention  is  directed  in  another  way,  the  back  will  be' 
seen  to  move  with  comparative  freedom. 


Fig.  167.— Pectus  Carinatum,  Showing  Flattening  of  the  Sides  of  the  Chest.    (Stone.) 

A  gait  which  is  very  similar  to  that  of  Pott's  disease  may  be  present, 
and  also  rigidity  of  the  back  in  rising  or  stooping.  As  in  that  affection 
continued  standing  and  walking  may  cause  pain,  the  patient  is  very  sen- 
sitive to  any  jar  and  may  be  relieved  from  discomfort  in  the  recumbent 
position. 

A  careful  examination  of  the  patient  usually  shows  that  the  symp- 


OTHER   AFFECTIONS    OK    THE    i-PINK. 


163 


toms  of  stiffness  are  more  from  an  apprehension,  of  possible  pain  of  move- 
ment than  from  the  unconscious  muscular  spasm  seen  in  the  acute  stages 
of  early  Pott's  disease.  Pain  on  movement,  moreover,  is  usually  much 
greater  than  is  seen  in  early  Pott's  disease. 

Unnatural  attitudes  may  be  assumed  on  account  of  the  sensitiveness, 


Fig.  168.— Harrison's  Sulcus  in  Rickets.    The  lower  border  of  the  pleura  and  pericardium  is  marked. 

(Stone.) 


such  as  a  rounding  out  of  the  whole  back  in  the  dorsal  region  or  a  slight 
lateral  deviation. 

The  spinal  muscles  and  often  the  muscles  in  general  are  weak  and 
flaccid. 

The  treatment  consists  in  the  improvement  of  the  general  condition 


1(U 


ORTHOPEDIC   SURGERY 


and  in  many  cases  in  the  use  of  measures  usually  indicated  in  neurasthe- 
nia.    Rest  to  the  back  must  be  secured  by  recumbency  for  part  of  the 


FIG.  169.— Funnel  Chest.    (Stone.) 


day,  followed  by  massage  and  exercises  to  strengthen  the  spinal  muscles. 
The  use  of  apparatus  is  sometimes  indicated  temporarily  to  enable  the 
patients  to  assume  the  upright  position  in  order  that  they  may  take  exer- 
cise and   set  out  of  doors.      In  general  the  treatment  of  hysterical  spine 


OTHER   AFFECTIONS   OF   THE    SPINE.  L65 

* 

does  not  differ  from  that  of  the  treatment  of  functional  affections  of  the 

joints. 

Distortion    of   the   Thorax. 

A  distorted  condition  of  the  chest  may  result  as  a  secondary  conse- 
quence of  curves  of  the  spine,  or  it  may  be  congenital.  The  congenital 
deformities  are  rare.     The  sternum  may  be  absent. 

Pigeon  breast  (Huhnerbrust,  Kahnbrust,  pectus  carinatum  or  gallina- 
tum,  poitrine  en  earene,  poitrine  de  pigeon,  etc.)  is  a  deformity  charac- 
terized by  a  prominence  of  the  sternum  and  cartilages  of  the  ribs.  It 
occurs  in  young  children  more  often  than  in  adults  and  is  most  often  due 
to  rickets.  It  occurs  also  as  the  result  of  nasal  or  pharyngeal  obstruction 
in  growing  children.  It  is  seen  often  to  an  extreme  degree  in  dorsal 
Pott's  disease,  in  which  it  is  due  to  the  sinking  forward  of  the  upper  dorsal 
spine  carrying  with  it  the  ribs.  Some  unilateral  prominence  of  the  costal 
cartilages  and  anterior  border  of  the  ribs  may  result  from  scoliosis. 

In  severe  rickets  lateral  flattening  of  the  chest  occurs,  along  with  a 
transverse  groove  below  the  nipples,  known  as  Harrison's  sulcus;  below 
this  sulcus  the  lower  part  of  the  chest  flares  out. 

Funnel  chest  (Trichterbrust,  etc.)  is  the  name  applied  to  a  depression 
of  the  sternum  and  costal  cartilages  the  etiology  of  which  is  not  always 
clear.  It  may  occur  to  some  extent  in  Pott's  disease  and  in  mild  rickets, 
while  in  many  cases  it  is  not  possible  to  assign  a  cause. 

The  deformities  of  the  chest  being  as  a  rule  secondary  to  other  affec- 
tions, their  treatment  is,  of  course,  so  far  as  possible,  the  removal  of  their 
cause.  For  the  condition  itself  apparatus  is  of  little  use,  but  gymnastics 
may  be  of  value. 


CHAPTER  IT. 

THE   PATHOLOGY,    ETIOLOGY,    AND    COURSE    OF   CHRONIC 

JOINT    DISEASE. 

I.  Joint  diseases  beginning  in  the  synovial  membrane:  chronic  serous  synovitis, 
chronic  purulent  synovitis,  chronic  synovitis  without  effusion. — II.  Joint  dis- 
eases beginning  in  bone:  tuberculosis,  acute  infectious  osteomyelitis,  tumors  of 
the  bones  involving  the  joints,  simple  ostitis. — III.  Joint  diseases  in  constitu- 
tional affections:  (1)  syphilis;  (2)  arthritis  deformans;  (3)  rheumatism;  (4) 
gout ;  (5)  acute  infectious  diseases  ;  (6)  gonorrhoea  ;  (7)  pathological  conditions  of 
the  nervous  system  ;  (8)  haemophilia  ;  (9)  scurvy. — IV.  Miscellaneous  conditions  : 
loose  bodies,  peri-articular  abscess,  growing  pains,  ankylosis,  bursitis,  etc. 

The  pathology  of  chronic  joint  disease  is  a  subject  the  literature  of 
which  is  very  extensive,  especially  in  this  transition  period ;  for  no  part 
of  the  pathological  domain  has  experienced  greater  or  more  radical 
changes  in  the  last  few  years,  and  to-day  one  has  no  accepted  classifica- 
tion and  no  definite  pathological  system.  A  great  deal  has  been  written, 
but  it  has  yet  to  be  crystallized  into  some  definite  scheme. 

No  attempt  will  be  made  here  to  treat  exhaustively  the  very  extensive 
subject  of  the  pathology  of  chronic  joint  disease,  but  simply  to  present 
it  in  its  practical,  surgical  aspect,  and  in  its  very  important  clinical 
relations. 

Most  of  the  diseases  of  the  joints  may  be  considered  under  one  of  the 
two  following  headings.  Other  affections  demand  separate  considera- 
tion. 

I.  Diseases  beginning  in  the  synovial  membrane. 

II.  Diseases  beginning  in  the  bones. 

I.   Diseases  Beginning  in  the  Synovial  Membrane. 

Chronic  synovitis  appears  as  chronic  serous  synovitis,  chronic  purulent 
synovitis,  or  chronic  synovitis  without  effusion. 

Chronic  serous  synovitis  is  also  known  by  the  names  of  dropsy  of  the 
joint,  hydrarthros,  hydrarthrosis,  hydrops  articulorum  chronicus,  etc. 
As  a  rule,  pathological  changes  are  present  in  the  synovial  membrane  of 
a  character  about  to  be  described ;  but  certain  cases  show  no  obvious 
pathological  changes  beyond  increase  of  fluid  for  a  long  time.1 

1  Frierichs :  Wagner,  " Handworterbuch  der  Phys.,"  iii.,  1446;  "Diet,  de  MeU 


THE   PATHOLOGY   OF   CHRONIC   .JOINT   DISEASE.  167 

The  most  common  form  of  chronic  serous  synovitis  is  that  which 
succeeds  one  attack  or  a  series  of  attacks  of  a  cutesynovitis,  and  here  the 
pathological  changes  are  evident,  although  they  are  at  first  very  slight. 
One  sees  in  the  commencement  only  a  slight  increase  of  vascularity  and 
a  tendency  to  thickening  of  the  membrane,  which  begins,  perhaps,  to  look 
boggy  from  soaking  in  the  excess  of  joint  fluid.  This  fluid  may  be  in- 
significant or  very  large  in  amount;  it  is  ordinarily  yellowish  or  color- 
less, but  at  times  it  is  red  from  blood  originally  effused. 

Increased  vascularity  and  thickening  of  the  membrane  are  followed 
by  an  hypertrophy  of  the  synovial  fringes.  This  hypertrophy  varies 
from  a  slight  and  almost  imperceptible  hyperplasia  to  a  condition  in  which 
the  fringes  are  transformed  into  a  mass  of  fibrous  polypi,  so  that  the 
synovial  surface  may  be  fairly  shaggy.  At  other  times  the  fringes  are 
translucent,  seeming  to  be  (as  they  often  are)  fat  enclosed  in  a  delicate 
capsule. 

Meantime,  the  subsynovial  tissue  has  hypertrophied,  and  in  some 
cases  it  is  known  to  have  increased  to  an  inch  in  thickness,  and  if  the 
fluid  has  been  long  in  the  joint  the  synovial  membrane  and  the  parts  be- 
low it  look  light  yellow,  pulpy,  and  boggy.  If  the  effusion  has  been  ex- 
treme the  capsule  has  either  become  enormously  thickened  or  has  become 
much  distended.  If  so,  the  lateral  and  internal  ligaments,  weakened  by 
the  continual  tension  and  soaked  by  the  contained  fluid,  have  also 
stretched,  and  lateral  motion  may  be  found  in  the  knee-joint,  even  to  the 
extent  of  60°. 

There  may,  however,  have  been,  instead,  a  development  of  cysts  in 
connection  with  the  joint,  practically  hernia?.  These  occur  oftenest  in 
the  popliteal  space  in  connection  with  the  knee-joint.  (Baker).1  The 
view  is  advanced  by  Kiese2  that  these  cysts  are  rather  the  result  of  cystic 
degeneration  of  periarticular  structures.  This  theory  is  based  upon 
the  obliteration  of  the  blood-vessels. 

The  most  common  causes  of  chronic  serous  synovitis  are  traumatism, 
exposure  to  cold,  rheumatism,  the  presence  of  loose  bodies,  etc. 

The  outcome  of  simple  serous  synovitis  is  in  absorption  or  suppura- 
tion, or  a  persistence  of  the  condition  with  a  continually  increasing  dis- 
ability of  the  joint. 

One  form  of  chronic  synovitis  is  marked  by  such  periodicity  that  it  is 
spoken  of  as  intermittent  hydrops.*  No  changes  may  be  found  in  such 
joints,  although  the  affection  may  have  existed  at  times  for  years.     No 


et  cle   Chir.  pratique,"  8,  80;  Bonnet:    "Mai.    des   Artie."  Paris,  1845;    Billroth: 
"Surg.  Path.,"  1883,  Am.  ed.,  p.  578;  Arch.  f.  kl.  Ch.,  ii.,  408. 
St.  Barth.  Reports,  xiii. 

2  Cent.  f.  Chir.,  1898.  p.  585. 

3Weisz:    Berl.   Klinik,    1898.    No.    119.   Senator:  Charity   Annalerj,  Bd.  xxi ; 
Seeligmiiller:  Deutsch.  med.  Wochensch.,  1880,  51. 


168 


ORTHOPEDIC   SURGERY. 


etiology  has  been  determined  and  the  disturbance  is  thought  to  be  vaso- 
motor in  character.  The  time  of  appearance  of  successive  attacks  is 
remarkably  regular,  the  interval  being  usually  about  a  fortnight. 

Chronic  purulent  synovitis,  or,  rather,  purulent  arthritis,  aside  from  the 
tuberculous  form. (which  will  be  considered  in  speaking  of  diseases  origi- 
nating in  bone),  may  be  consecutive  to  the  infectious  acute  inflammations, 
or  the  infection  may  have  extended  from  neighboring  parts.  The  joint 
is  in  these  cases  filled  with  pus  and  the  synovial  membrane  infiltrated 
and  covered  with  a  fibrinous  deposit.  The  cartilage  in  cases  of  long 
standing  becomes  cloudy  and  fibrillatecl,  and 
necrosis  may  occur  in  spots.  If  the  process  is 
continued  long  enough  the  ends  of  the  bone  be- 
come involved  and  carious  abscesses  are  likely 
to  occur.  Eecovery  then  takes  place  by  the 
formation  of  cicatricial  adhesions  and  the  de- 
posit of  new  bone. 

Chronic  dry  synovitis  is  found  as  a  senile 
change,  not  always  distinguishable  from  rheu- 
matoid arthritis,  as  a  neuropathic  disorder,  and 
as  the  result  of  the  fixation  of  joints  in  one 
position.  In  Key  her' s  experiments,  at  the  end 
of  a  year' s  fixation  it  was  found  that  the  car- 
tilages of  the  joints  had  degenerated  at  the 
points  where  they  were  not  in  contact. '  In  such 
joints  with  a  shortened  capsule  and  thickened  synovial  membrane  for- 
cible manipulation  may  rupture  the  ligaments  and  produce  hemorrhage 
from  the  synovial  outgrowths. 

In  the  "  ulcerative  "  form  there  is  a  fibrillation  and  a  disintegration  of 
the  articular  cartilages.  This  is  accompanied  by  thickening  of  the  cap- 
sule and  hypertrophy  of  the  synovial  folds  and  fringes.  Lime  salts  may 
be  deposited  in  the  capsule  and  cartilage,  and  as  the  latter  wears  away 
the  ends  of  the  bone  become  eburnated  and  sclerotic. 

Chronic  dry  synovitis  also  occurs  in  the  form  known  as  "  ankylosing  " 
(arthritis  ankylopoetica).  This  may  be  the  result  of  an  acute  exudative 
inflammation  or  as  the  final  stage  in  chronic  destructive  processes.  It 
occurs  also  in  chronic  rheumatism. 


Fig.  170.— Chronic  Arthritis  Fol- 
lowing Wound.  (Warren  Mu- 
seum.) 


'Menzel:  Langenbeck's  Archiv,  xii.  ;  Moll-  "Enters,  liber  d.  anat.  Zustand 
d.'Gelenke  bei  andauernder  Immobilization,"  Berlin,  1885;  Reyher  Deutsch  Zeit. 
f.  Ch.,  xii.,  1873;  Volkmann :  "  Hydrarthros,"  Berlin,  klm.  Wochensch.,  1870. 


THE    PATHOLOGY   OF   CHRONIC   JOINT    DISEASE.  Hi'J 


II.  Joint  Diseases  Beginning  in   Bone. 

TUBERCULOSIS. 

The  modern  view  justifies  the  consideration  of  tuberculous  joint  dis- 
ease under  this  heading.  This  class  of  affections  has  from  time  to  time 
been  described  under  the  following  names:  Tuberculous  ostitis  or  osteo- 


FlG.  J 71.— Tumor  Albus.  Small  focus  in  upper  epiphyseal  line  of  tibia.  Synovitis  of  joint,  but  no  tu- 
berculous process  apart  from  focus  as  noted.  Death  from  miliary  tuberculosis,  a.  Epiphysis;  b,  pri- 
mary focus ;  c,  shaft.    (Nichols.) 

myelitis,  tuberculosis  of  joints,  scrofulous  or  strumous  joint  disease, 
caries,  fungous  joint  disease,  gelatinous  arthritis,  white  swelling. 

It  is  called  in  German,  scrofulose  Caries,  tuberculose  Caries,  scrofu- 
lose  Gelenkentzilndung,  and  fungose  Arthritis,  Gelenktuberculose,  etc. 

In  Latin,  Caries  mollis  sive  fungosa,  fungus  articuli,  caries  sicca,  etc. 

French  names  aim  at  greater  precision  in  speaking  of  osteo-periostite 
tuberculose  chronique,  tuberculose  articulaire,  tubercule  tardif  a  evolu- 
tion rapide,  and  osteite  aigue. 

In  whatever  joint  it  appears  it  presents  itself  in  much  the  same  form, 
as  an  affection  of  the  spongy  tissue  of  the  epiphysis,  most  often  near  its 


b    "' 


Fig.  172.-Hip  Disease.    Primary  tuberculous  focus  in  head  of  femur,  near  epiphyseal  line,    a,  Head  of 
femur ;  b,  tuberculous  focus  in  epiphyseal  line.    (Nichols.) 

line  of  junction  with  the  shaft ;  but  sometimes  near  the  articular  carti- 
lage, and  rarely  in  the  periosteum.  It  occurs  mostly  as  a  localized  dis- 
ease, appearing  in  one  or  more  distinct  foci ;  a  simultaneous  tuberculous 


I7n 


ORTHOPEDIC    SURGERY 


infiltration  of  the  whole  epiphysis  (the  infiltrated  tubercle  of  Nelaton), 
however,  rarely  happens. 

The  common  form  of  tuberculous  infection  of  the  epiphyses  is  the  one 
spoken  of  as  focal  or  encysted,  when  the  first  change  is  the  formation  of 

single  or  multiple  foci  of 
tuberculous  degenera- 
tion. On  section  of  the 
diseased  epiphysis  the 
first  noticeable  change 
consists  in  a  local  hy- 
peremia of  some  part 
of  the  spongy  tissue. 
There  then  appears  in 
this  hypenemic  area  a 
small  grayish  translu- 
cent spot  almost  as  small 
as  one  can  see,  which 
grows  more  gray  and 
increases  in  size,  while 
a  zone  of  hypereemic  tis- 
sue develops  around  it 
and  the  neighboring 
bone  looks  boggy  from 
an  excess  of  the  trans- 
uded fluid.  At  first 
usually  there  is  no  sy- 
novitis, it  is  purely  a 
localized  ostitis. 

Under  the  micro- 
scope the  process  ap- 
pears to  be  as  follows: 
The  tubercle  bacilli, 
being  lodged  in  the 
marrow  of  the  bone, 
cause  a  multiplication 
of  the  surrounding  cells, 
probably  by  the  action 
of  a  toxin,  and  a  typi- 
cal tubercle  is  formed. 
Such  an  area  consists  of  a  central  mass  of  giant  and  epithelioid  cells 
surrounded  by  a  zone  of  lymphoid  cells.  As  the  tuberculous  area  in- 
creases by  multiplication  of  the  cells,  the  centre  degenerates,  form- 
ing a  necrotic  mass  in  which  fat  drops  may  be  seen.  Sometimes  the 
tubercle  bacillus  can  be  found,  usually  in  small  numbers,  in  the  giant 


Fig.  173.— Section  of  Tuberculous  Synovial  Membrane.    (Nichols.) 


THE   PATHOLOGY    OF   CHRONIC   JOINT   DISEASE. 


in 


cells,  or  in  the  epithelioid  cells,  or  between  them.  The  process  extends 
by  the  formation  of  other  tubercles,  apparently  due  to  the  multi- 
plication of  the  tubercle  bacilli  and  their  diffusion  through  the  tis- 
sues. New  necrotic  areas  like  the  first  are  found  which  coalesce  and 
form  a  mass  of  caseous  material.  Around  the  tuberculous  area  there  ap- 
pears a  zone  of  non-tuberculous  granulation  tissue  early  in  the  process. 


Fig.  174.— Edge  of  Tuberculous  Focus  in  Bone.  A  portion  of  caseous  marrow  surrounded  by  necrotic 
bone  trabecular  Outside  this  is  an  area  of  tubercles,  and  still  farther  from  the  centre  is  fat  marrow 
with  much  cedematous  fibrous  tissue.    (Nichols.) 

During  the  later  and  reparative  stages  of  the  process  this  area  becomes 
less  vascular  and  is  converted  into  denser  fibrous  tissue. 

As  the  individual  tubercles  meet  and  coalesce  they  form  in  the  mar- 
row of  the  bone  irregular  caseous  masses.  In  this  way  large  areas  of 
bone  may  be  involved  by  peripheral  enlargement  of  the  tuberculous  area. 
This  area  may  soften  and  a  tuberculous  bone  abscess  may  result,  the  puru- 
lent material  containing  bone  fragments  like  sand. 

Instead  of  forming  a  "  bone  abscess "  the  process  may  result  in  the 
formation  of  a  sequestrum  composed  of  necrotic  trabecular  retaining  their 
shape  and  lying  in  a  cavity  in  the  bone.     About  the  sequestrum    is  a 


Ir2 


ORTHOPEDIC   SURGERY. 


layer  of  granulation  tissue.  The  sequestrum  may  take  the  shape  of  a 
wedge  having  its  base  toward  the  joint,  in  which  case  it  is  known  as  a 
"  bone  infarct. " 

As  the  diseased  focus  grows  larger  it  looks  more  yellow  in  spots,  and 
shows  at  its  centre  a  tendency  to  cheesy  degeneration,  and  later  in  the 
history  of  the  affection  one  finds  nodules,  varying  in  size  from  that  of  a 
pea  to  a  hazelnut,  which  are  tilled  with  a  putty -like  substance,  such  as 


Fig.  175.— Perforation  of  Articular  Cartilage  from  Bone  Focus.     Shows  tubercle  in  bone  marrow. 
Cartilage  is  somewhat  flbrillated,  and  contains  numerous  irregular  cavities  filled  with  spindle-shaped 

cells.    (Nichols.) 

the  cheesy  material  found  elsewhere  in  the  body,  except  that  it  contains 
spicules  of  bone  from  the  trabecular,  and  in  the  larger  foci  pieces  of  dead 
bone  of  considerable  size  are  found. 

Later  in  the  history  of  the  affection  the  tuberculous  nodule  may  break 
down  into  purulent  material. ' 

Generally  the  original  focus  is  surrounded  by  smaller  tubercles  which 
aid  in  its  extension ;  but  the  chief  work  is  done  by  the  erosive  action  of 
the  granulations,  which  take  the  place  of  the  progressively  rarefied  bone. 

From  the  stage  of  tuberculous  infiltration  the  process  may  follow  any 
one  of  three  courses:  the  diseased  focus  may  be  absorbed  and  so  cured; 
it  may  extend  to  the  periphery  of  the  bone,  and  break  through  the  peri- 
osteum and  empty  itself  there ;  or,  lastly  and  probably  most  commonly, 
it  may  extend  to  the  joint  and  infect  that. 

(1)  The  absorption  of  the  diseased  focus  is  theoretically  possible  up 

1  Vincent's  article,  Ashhurst's  Encyclopaedia,  vol.  vi.,  p.  908. 


THE   PATHOLOGY   OF   CHRONIC   JOINT   DISEASE. 


17:; 


to  a  late  stage  in  the  process,  so  long  as  the  disease  remains  strictly  local 
and  no  sequestra  of  any  size  have  formed;  the  pus  may  become  cheesy 
and  calcified. 

(2)  The  next  most  favorable  termination  to  the  disease  is  when  the 
focus  does  not  infect  the  joint  but  breaks  through  the  periosteum,  and 
discharges  into  the  peri-articular  structure.  This  happens  when  the  focus 
is  so  situated  that  the  line  of  least  resistance  takes  it  to  another  part  of 
the  bony  surface  away  from  the  joint,  there  forming  probably  an  abscess 
which  must  be  evacuated  externally  or  break.  Sometimes  this  ends  the 
disease;  the  granulation  tissue  becomes  fibrous,  and  then  osseous,  and 


/ 


^."SS^ 


Fig.  176.— Spina  Ventosa  of  Finger.    Shows  original  shaft ;  marrow  caseous  or  infiltrated  with  tuber- 
*  eles.    Cartilage  nearly  normal.    Periosteum  thick  and  tuberculous.    No  periosteal  new  bone.    (Nichols.) 

the  disease  is  over.  This,  according  to  Krause,  is  most  likely  when  the 
focus  is  in  the  upper  or  lower  end  of  the  tibia  or  in  the  olecranon.1  It 
is  not  likely  to  occur  in  the  hip  on  account  of  the  extensive  distribution 
of  the  capsule. 

(3)  Probably  the  commonest  course  for  this  localized  ostitis  to  pursue 
is  to  break  into  the  joint  cavity,  and  the  ease  with  which  infection  of  the 
joint  from  the  epiphysis  is  produced  will  be  readily  understood  by  con- 
sidering the  pathological  conditions. 

The  seat  of  the  disease  in  the  beginning  is  ordinarily  not  far  from  the 
cartilage.  At  first  it  excites  no  joint  inflammation,  but  when  it  reaches 
a  certain  stage,  even  before  it  breaks  into  the  joint,  inflammatory  reac- 


1  Krause  :  "Tub    der  K.  und  Gelenke,"  1801. 


174  ORTHOPEDIC   SURGERY. 

tion  in  the  joint  begins.1  The  inflammation  of  the  joint  at  first  is  non- 
tuberculous,  the  synovial  membrane  appearing  thick  and  edematous,  the 
cavity  of  the  joint  being  filled  with  a  serous  inflammatory  exudate.  This 
process  may  be  very  extensive,  and  Yolkmann3  claimed  that  obliteration 
of  the  joint  cavity  might  occur  from  the  cicatrization  of  the  non-tuber- 
culous inflammatory  process. 

Perforation  of  the  joint  by  the  tuberculous  focus  is  the  next  step  in  the 
process.  When  the  tuberculous  focus  underlies  it,  the  cartilage  of  the 
joint  begins  to  disintegrate  and  appears  softened  and  yellow  and  finally 
breaks  through.  The  perforation  frequently  occurs  near  ligaments. 
The  tubercle  bacilli,  having  entered  the  joint,  are  quickly  disseminated 
by  movement  of  the  articulation,  and  the  synovial  membrane  becomes 
infected. 

The  synovial  membrane  then  appears  thick,  smooth,  and  shining  and 
sometimes  nodular,  the  surface  is  studded  with  small  specks  not  larger 
than  the  head  of  a  pin.  The  yellow  tuberculous  areas  increase  and  soften, 
and  tuberculous  ulcers  of  the  synovial  membrane  form.  The  thickened 
synovial  membrane  extends  as  a  pannus  growth  over  the  edge  of  the 
articular  cartilage,  sometimes  covering  the  whole  cartilage.  At  the  same 
time  the  tuberculous  process  may  extend  between  the  cartilage  and  bone. 
The  cartilage  beneath  the  pannus  layer  is  destroyed  and  disintegrated 
while  the  free  surface  of  the  cartilage  becomes  fibrillated  and  ulcers  ap- 
pear in  it  also.  When  the  tuberculous  process  extends  beneath  the  car- 
tilage the  latter  is  eroded  and  destroyed. 

Large  areas  of  cartilage  may  be  detached  from  the  underlying  bone, 
and  sometimes  the  entire  cartilage  may  be  loosened  as  in  the  hip-joint. 
Under  these  conditions  the  denuded  end  of  the  bone  is  seen  to  be  covered 
with  nodular  granulation  tissue  filled  with  tubercles,  caseous  and  other- 
wise. As  the  disease  goes  on  the  cartilage  is  destroyed  or  cast  off  in 
sheets,  and  the  denuded  bones  are  attacked  by  the  tuberculous  process  and, 
are  eroded.  As  a  result  of  this,  articular  cavities  are  enlarged  and  dis- 
torted, and  distortions  and  subluxations  may  occur.  The  tonic  muscular 
contraction  accompanying  joint  disease  tends  in  certain  joints  to  crowd 
together  the  softened  ends  of  the  bones  and  hasten  the  wearing  away. 

Microscopical  examination  of  the  diseased  area  at  any  time  before  ah 
structure  is  lost  shows  a  typical  granulating  tuberculosis.  Writhin  the 
low-grade  granulation  tissue  one  finds  numerous  and  characteristic  tuber- 
cles with  epithelioid  and  giant  cells  (Konig),  but  with  the  increase  of 
cheesy  degeneration  the  typical  tuberculous  structure  becomes  more  and 
more  obscure. 

Thickening  of  the  capsule,  infiltration  of  the  peri-articular  tissues,  and 


1  Lannelongue  :  "Coxo-tuberculose,"  Paris,  1886. 
sVolkmann:  Samml.  klin.  Vortr.,  No.  52. 


THE   PATHOLOGY   OF   CHRONIC  JOINT   DISEASE. 


175 


thickening  of  the  ends  of  the  hones  are  clinical  manifestations,  and  ah- 
scess  formation  and  all  the  other  complications  are  ready  to  follow. 

About  the  affected  joint  is  formed  a  layer  of  granulation  tissue  which 
may  be  converted  into  fibrous  tissue.  This  process  may  be  very  exten- 
sive and  accounts  for  such  phenomena  as  the  ovoid  swelling  in  tumor 
albus  and  the  thickening  of  the  trochanter  in  hip  disease.  This  fibrous 
tissue  may  be  oedematous, 


,'■'.'.' v,",  ■ 
■&■■ 


mi:      ~m 


'?!■*':  ■;*••, 


r:'-  '■'■■?-'" 


r::s&>>,    teas ! 


and  the  spaces  may  con- 
tain a  fluid  reacting  to 
stains  like  mucin. 

Repair  is  brought 
about  by  the  formation 
of  fibrous  tissue,  probably 
arising  from  the  layer  of 
non-tuberculous  granula- 
tion tissue  which  grows 
into  and  replaces  the  tu- 
berculous material.  Case- 
ous material  is  largely 
absorbed,  and  the  inspis- 
sated remainder  is  re- 
placed by  fibrous  tissue 
or  is  calcified  and  encap- 
sulated. Fibrous,  carti- 
laginous, or  bony  anky- 
losis may  result  from  the 
process  of  repair. 

It  is  most  important 
to  note  that  the  process 
of  repair  may  be  incom- 
plete, and  that  small 
areas  of  tuberculous  ma- 
terial encapsulated  by 
fibrous  tissue  may  persist 
for  a  long  time  and  under 
favorable  conditions  may 

become  active  and  cause  a  recurrence  of  the  disease.  This  fact  must 
always  be  borne  in  mind  in  forcibly  manipulating  convalescent  tuberculous 
joints. 

Certain  variations  of  this  process  must  be  described.  Other  types 
of  synovial  affection  from  that  described  are  found  at  times. 

Arborescent  tuberculous  synovitis  is  the  name  given  to  a  condition  in 
which  the  synovial  membrane  is  covered  with  branching  arborescent  tags 
frequently  coated  with  fibrin.     These  tags,  which  may  be  of  considerable 


Fig.  177.— Section  of  Tuberculous  Synovial  Membrane.  Numer- 
ous tubercles  with  giant  cells.  Between  these,  oedematous  granu- 
lation tissue  with  many  lymphoid  and  plasma  cells.    (Nichols.) 


17*'.  ORTHOPEDIC   SURGERY. 

size,  consist  of  vascular  connective  tissue  containing  tubercles.  Some- 
times a  large  amount  of  fatty  tissue  may  be  present,  constituting  the 
"  lipoma  arborescens. " 

Solitary  tuberculous  nodules  of  the  synovial  membrane  are  described 
by  Konig,  "Eiedel,  Krause,  and  Cheyne.  Nodular  and  even  polypoid 
growths  with  little  tendency  to  caseation  project  into  the  joint.  Although 
at  first  the  rest  of  the  synovial  membrane  is  but  little  affected  it  becomes 
involved  later. 

It  ice  bodies  are  occasionally  found  free  or  pedunculated  in  tuberculous 
joints.  They  consist  either  of  fibrin  arranged  in  concentric  layers  or  of 
vascular  connective  tissue. 

Hydrops  articulorum  tuberculosus  was  a  name  given  by  Konig  to  a 
chronic  effusion  of  joints  said  to  be  primarily  synovial.     In  these  there 


Fig.  178.— Tuberculous  Disease  of  Knee  Excision.    View,  from  above,  of  upper  end  of  tibia.    Shows 
large  oval  area  of  tuberculous  softening.    Clinical  history  not  known.    (Nichols.) 

is  said  to  be  at  first  no  marked  thickening  of  the  synovial  membrane. 
Later  the  membrane  assumes  the  typical  character  of  tuberculous  synovial 
inflammation.  A  similar  condition  of  joints  with  a  purulent  effusion  is 
described  as  "empyema  tuberculosum. " 

It  has  always  been  asserted  by  writers  on  bone  tuberculosis  that 
primary  disease  of  the  synovial  membrane  occurred.  Volkmann,  how- 
ever, as  early  as  the  writing  of  his  classical  monograph,  said :  "  The 
fungous  inflammations  of  the  joints  begin  generally,  and  in  children 
almost  without  exception,  not  at  all  as  an  arthropathy,  but  as  a  pure 
osteopathy,  with  a  very  circumscribed  caseous  or  tuberculous  ostitis."  '' 

Nichols2  in  one  hundred  and  twenty  tuberculous  joints  examined  from 
children  and  adults,  many  from  excisions,  a  considerable  number  from 

1  Volkmann:  Klin.  Vortr.,  v.,  p.  1405. 
5  Nichols:  Orth.  Trans.,  vol.  xi.,  p.  383. 


THE    PATHOLOGY    OP   CHRONIC   JOINT   DISEASE. 


177 


autopsies  or  amputations,  did  not  see  a  joint,  in  which,  if  all  the  bones  en- 
tering into  the  joint  were  sawed  open,  one  or  more  old  bone  foci  were  not 
found. 

Krause  admits  that  the  more  one  makes  it  a  rule  to  saw  open  the 
bones  the  less  often  will  cases  be  considered  primary  disease  of  the  syno- 
vial membrane.  Complete  examination  of  a  joint  at  operation  is  usually 
difficult  and  oftenest  impossible,  so  that  conclusions  as  to  the  absence  of 
primary  bone  disease  based  upon  such 
examinations  must  be  accepted  with 
caution. 

Although  primary  tuberculosis  of 
the  synovial  membrane  is  described  by 
those  whose  statements  carry  great 
weight,  the  results  of  Nichols'  investi- 
gations must  be  borne  in  mind,  which 
are  positive  and  not  negative  con- 
clusions. 

The  writers  are  of  the  opinion  that 
primary  disease  of  the  synovial  mem- 
brane is  a  diagnosis  warranted  only 
after  all  bones  forming  the  joint  have 
been  sawed  open  in  all  parts.  And 
that  for  clinical  purposes,  until  the 
contrary  is  proved,  one  must  assume 
that  practically  all  tuberculous  joint 
disease  has  its  origin  in  bone. 

Cold  Abscesses  of  Joints. — If  the 
tuberculous  process  in  the  bone  reaches 
the  surrounding  tissues  by  perforation 
of  the  cortex  and  periosteum  or  by 
rupture  of  the  joint  capsule  an  abscess 
is  likely  to  occur.  The  area  of  tuber- 
culous softening  in  the  peri-articular 
tissues  is  formed  by  the  coalescence 
and  caseation  of  tubercles.  Surround- 
ing the  softened  area  is  a  layer  of  tuberculous  tissue  about  which  is  an- 
other layer  of  (Edematous  and  vascular  granulation  tissue.  This  process 
may  extend  until  a  large  cavity  has  been  formed. 

The  contents  of  these  abscesses  are  composed  of  caseous  material 
from  the  degeneration  of  the  tubercles  and  exuded  serum  with  necrotic 
pieces  of  bone.  In  the  fluid  are  polymorphonuclear  leucocytes,  often 
taking  up  little  or  no  stain  on  cover  slips.  Pyogenic  organisms  are 
absent  unless  present  by  secondary  infection.  The  fluid  may  be  like 
true  pus;  it  may  be  so  thick  that  it  will  hardly  flow;  it  may  be  thin  and 


Fig.  179.— Fibula  from  Tumor  Albus.  Joint 
showed  general  tuberculous  synovitis.  No 
other  foci.  No  apparent  communication  with 
the  joint,  a.  Femur ;  h,  tuberculous  focus  ;  c, 
fibula.     (Nichols.) 


ITS 


ORTHOPEDIC   SURGERY. 


watery  and  contain  coagula,  or  it  may  be  red  or  brownish  from  hemor- 
rhage. 

Microscopically  tubercle  bacilli  may  be  found  in  the  abscess,  but  they 
are  to  be  identified,  even  after  prolonged  search,  in  only  about  one-third 
of  the  cases,  according  to  Krause.  In  such  cases  inoculation  experiments 
must  be  relied  upon  to  establish  their  presence. 

The  wall  of  these  abscess  cavities  is  composed  of  an  inner  layer  of 
tuberculous  tissue,  outside  of  which  is  a  layer  of  secondary  inflammatory 


:-$r'0::'^y''-:- 


^""^Sift  i  ^  war..  a-V.  -iiv.y  .  ■B? 


Fig.  180.— Wall  of  Tuberculous  Sinus.    Numerous  tuberculous  areas  surrounded  by  oedematous  granula- 
tion tissue,  in  which  are  many  lymphoid  and  plasma  cells.    (Nichols.) 

tissue.  The  inner  layer  may  be  granular  or  necrotic  and  ulcerated.  The 
abscess  extends  by  peripheral  enlargement  in  the  line  of  least  resistance. 
The  walls  of  tuberculous  sinuses  consist  of  an  inner  layer  of  tuberculous 
tissue  outside  of  which  is  a  zone  of  oedematous  granulation  tissue. 

This  type  of  joint  disease  is  considered  tuberculous  for  the  following 
reasons : 


THE    PATHOLOGY   OF   CHRONIC   JOINT    DISEASE.  179 

1.  Tubercles  can  be  identified  microscopically  in  practically  all  cases. 
On  this  subject  all  modern  writers  agree. 

2.  The  tubercle  bacillus  is  often  present.  Midler  believed  that  with 
care  they  could  usually  be  found.  Cheyne  believes  that  with  careful 
search  they  can  always  be  found.  Nichols  suggests  that  the  process  of 
decalcification  necessary  in  order  to  cut  microscopic  sections  of  bone  in- 
terferes with  the  staining  reaction  of  the  bacillus.  Bits  of  tuberculous 
lung  were  soaked  in  weak  nitric  acid,  and  after  two  days  the  bacilli 
stained  faintly  and  in  small  numbers,  and  after  four  days  no  bacilli  could 
be  detected. 

3.  Inoculation  of  animals  with  tissue  from  bones  and  joints  affected 
by  this  type  of  disease  produces  general  tuberculosis.' 

4.  Experimental  production  of  tuberculous  joint  disease  in  animals. 
Htiter  and  Schiiller3  rendered  animals  tuberculous  by  inoculation  and  by 
injuring  their  joints  produced  typical  joint  tuberculosis.  Midler'  in- 
jected tuberculous  pus  into  the  nutrient  artery  of  the  tibia  in  kids  and 
produced  tuberculous  disease  in  the  epiphysis  and  sometimes  in  the  shaft 
of  the  bone  and  in  the  joint.  Watson  Cheyne  produced  similar  results 
by  the  injection  of  pure  cultures  of  the  tubercle  bacillus.  Krause  injected 
pure  cultures  into  the  joints  of  animals  and  produced  tuberculosis  of  the 
joints.  He  also  confirmed  Schuller's  experiments  as  to  joint  injury  in 
animals  rendered  tuberculous.  Although  the  injured  joints  became  tu- 
berculous, fractured  bones  in  these  animals  healed  in  every  case  without 
showing  tuberculous  infection.     Triconi  performed  similar  experiments. 

5.  The  frequent  association  with  phthisis,  tuberculous  meningitis,  etc., 
of  this  type  of  joint  disease  helps  to  confirm  its  tuberculous  character,  if 
such  confirmation  were  needed.  Watson  Cheyne  reports  that  in  386  cases 
observed  for  three  years  42,  or  10.8  per  cent,  had  contracted  or  succumbed 
to  tuberculous  meningitis  of  phthisis.  In  2, 106  cases  of  carious  disease 
of  bones  and  joints  investigated  by  Billroth  and  Menzel  from  the  post- 
mortem records  at  Vienna  (1817-67)  52  per  cent  showed  tuberculosis  of 
the  internal  organs.  In  837  resections  of  the  hip  Wartmann  reports  that 
10  per  cent  of  the  patients  died  of  generalized  tuberculosis,  which  came 
on  in  such  a  way  as  to  suggest  that  the  operation  was  a  causative  factor. 

Billroth  found  that  54  per  cent  of  patients  dying  with  this  form  of 
joint  disease  die  of  acute  miliary  tuberculosis ;  Jaffe,  that  53  per  cent  of 
the  deaths  are  from  general  tuberculous  infection.5     Grosch's  extensive 

1  Cheyne  :  British  Med.  Jour.,  April,  1891. 

2Deutsch.  Zeit.  f.  Ch.,  1872,  xi.,  317. 

3  Schiiller:  "Exp.  und  histol.  Untersuchungen,"  Stuttgart,  1880. 

4 Cent.  f.  Ch.,  1886,  No.  14. 

5N.  Y.  Medical  Journal,  p.  325,  1884,  Garre  :  Deutsch  med.  Woch.,  No.  34, 
1886;  Triconi:  Baumgarten's  Jahresbericht,  ii.,  p.  229,  1886,  quoted  by  Dennis, 
N.  Y.  Med.  Assn.  Rep.,  ii.,  p.  331  ,  Grosch  .  Cent.  f.  Chir.,  228,  1882. 


180  ORTHOPEDIC    SURGERY. 

statistics  show  that  in  hip  disease  tuberculosis  is,  in  spite  of  antiseptic 
precautions,  the  commonest  cause  of  death.  Nor  does  the  removal  of  the 
diseased  joint  seem  to  diminish  this  liability  very  much.  Konig'  did  117 
resections  for  this  class  of  joint  diseases,  and  of  25  deaths  found  18  due 
to  general  tuberculosis,  and  9  more  patients  hopelessly  tuberculous. 

Caumont "  found  no  preventive  effect  in  resection,  for  in  26  cases  of 
hip  disease,  treated  expectantly,  one-fifth  succumbed  to  generalized 
tuberculosis,  while  12  others  were  resected  and  one-third  of  the  patients 
died  of  the  same  cause. 

6.  Human  beings  are  susceptible  to  tuberculous  inoculation.  Leh- 
mann3  relates  the  tuberculous  infection  of  10  children  (fatal  in  7)  who 
were  circumcised  by  a  phthisical  rabbi  in  a  small  continental  town. 
The  prepuce  became  the  seat  of  tuberculous  ulceration  and  the  inguinal 
glands  enlarged  and  suppurated.  Similar  cases  are  related  by  Elsen- 
berg, 4  Mecklen,  and  Hoist, 5  in  which  the  presence  of  bacilli  in  the  affected 
tissues  was  demonstrated. 

A  case  related  by  Pfeiffer  deserves  especial  mention.  A  veterinary 
surgeon  of  good  antecedents  and  in  sound  health  punctured  the  joint  of 
his  thumb  with  a  knife,  while  dissecting  a  tuberculous  cow;  a  synovitis  of 
the  tuberculous  tj-pe  followed,  and  he  died  in  a  year  and  a  half  of  phthisis. 
His  thumb  joint  showed  typical  tuberculous  structures  in  which  bacilli 
abounded.6 

General  miliary  tuberculosis  of  bone  occurs  in  connection  with  general 
miliary  tuberculosis.  The  marrow  is  studded  with  miliary  tubercles; 
necrosis  and  inflammatory  reaction  are  slight  or  are  absent.7 

Etiology  of  Tuberculous  Joint  Disease. 

Heredity. — That  heredity  is  a  factor  in  causing  tuberculous  joint  dis- 
ease has  long  been  admitted.  Whether  the  tuberculous  virus  can  be 
directly  transmitted  as  such  from  father  or  mother  to  the  offspring  must 
still  be  held  open  to  question. " 

Figures  which  attempt  to  shoAV  what  proportion  of  children  with  joint 
disease  inherit  a  tendency  to  these  diseases  are  notoriously  untrustworthy. 
In  the  class  of  hospital  patients  from  whom  most  of  these  statistics  come, 
anything  approaching  accurate  information  with  regard  to  the  diseases 

1  Konig:  Archiv  f.  kiin.  Chir.,  26,  p.  822. 

s  Caumont :  Deutsch.  Zeit.  f.  Chir.,  xx.,  137  ;  Yale:  N.  Y.  Medical  Journal, 
November  28th,  1885. 

'-Deutsch.  med.  Woch.,  1886,  9-13. 

4 Cent.  f.  Chir.,  1887,  p.  52. 

*  Quoted  by  Barber     Brit.  Med.  Jour. ,  June  23d,  1888. 

»;  Pfeiffer    Fort,  der  Med.,  1888,  No.  1,  p.  33. 

1  For  further  detail  the  reader  is  referred  to  the  article  of  Nichols  (Trans.  Am. 
Orth.  Assn.,  vol.  xi),  which  has  been  freely  used  by  the  writers. 

fc  Quoted  by  Cheyne  :  "Tuberculous  Disease  of  Joints,"  p.  97. 


THE    ETIOLOGY    OP   CHRONIC   .JOINT    DISEASE.  181 

of  which  relatives  have  died  cannot  be  expected.  There  is  also  an  in- 
clination on  the  part  of  parents  to  deny  the  existence  of  tuberculous  dis- 
ease in  their  parents  and  relatives.  In  this  way  parents  of  all  classes 
are  much  more  anxious  to  establish  some  traumatic  cause  for  the  affection 
of  the  joint  than  to  have  it  supposed  that  the  child  inherited  any  consti- 
tutional taint.  Again,  it  must  be  remembered  that  in  a  community  in  which 
approximately  ten  per  cent  of  all  deaths  are  from  phthisis,  phthisis  must 
necessarily  appear  in  the  family  histories  of  a  certain  proportion  of  any 
group  of  individuals  whose  antecedents  are  inquired  into.  For  these 
reasons  the  following  statistics  cannot  be  regarded  as  other  than  inaccu- 
rate, and  only  approximating  the  truth,  but  the  error  is  likely  to  lie 
always  on  one  side,  in  making  the  proportion  of  inheritance  too  small. 

Gibney1  analyzed  596  cases  of  different  tuberculous  joint  diseases,  and 
found  tuberculous  disease  in  one  or  both  parents  in  68  per  cent,  and  what 
he  calls  an  "  acquired  diathesis  "  in  30  per  cent  more ;  and  of  the  whole 
number,  after  a  close  investigation,  he  could  find  only  1  case  which  did 
not  present  an  acquired  or  hereditary  diathesis;  but  he  represents  an 
extreme  point  of  view  in  the  matter.  C.  Fayette  Taylor,2  in  the  analy- 
sis of  845  cases  of  Pott's  disease,  found  34  per  cent  in  which  there  was 
tuberculous  or  so-called  scrofulous  disease  in  the  parents,  and  in  66  per 
cent  the  disease  came  on  in  patients  of  a  sickly  diathesis.  In  401  cases 
of  hip  disease  from  the  Alexandra  Hospital  reports,  24  per  cent  had 
phthisis  in  the  family  history3  and  35  per  cent  were  classed  as  traumatic. 
Albrecht,  tabulating  325  cases  of  tuberculous  disease  of  various  joints  as 
to  etiology,  classed  33  per  cent  as  "associated  with  scrofula."  In  1,842 
cases  tabulated  from  Gibney,  Taylor,  and  Croft  41  per  cent  were  in  chil- 
dren, one  or  both  of  whose  parents  had  phthisis.' 

Traumatism.—  Experimentally  it  has  been  seen  that  trauma  to  the 
joint  of  a  tuberculous  animal  may  cause  tuberculous  joint  disease,  but 
that  it  does  not  do  so  in  the  healthy  animal.  It  has  been  established 
that  contusions  and  wrenches  cause  the  effusion  of  blood  in  the  spongy 
tissue  of  the  bone.  Konig  has  seen  cases  in  which  tubercles  developed 
directly  from  the  clot,  just  as  in  a  syphilitic  individual  a  gumma  may 
develop  at  the  site  of  an  injury  to  the  bone.  "  There  are  cases  in  which  the 
swelling  from  the  fall  merges  into  the  tuberculous  swelling. "  5  It  would 
therefore  seem  rational  to  assume  that  trauma  caused  tuberculous  joint 
disease  in  children  who  inherited  a  constitutional  taint.  But  it  becomes 
evident  at  once  that  this  is  not  all,  for  every  surgeon  of  experience  must 

1  Gibney  :  "Strumous  Element  in  Joint  Disease,"  N.  Y.  Med.  Jour.,  July,  1877. 
"-' From  preface  of  German  translation  of  "  The  Mechanical  Treatment  of  Pott's 
Disease." 

-Croft:  Clin.  Soc.  Transactions,  London,  vol.  xiii. 

JNichols:  Orth.  Trans.,  xi.,  p.  358. 

5 Konig:  Deutsch.  Zeit.  fur  Ohir.,  1879,  xi. 


182  ORTHOPEDIC   SURGERY. 

have  in  his  mind  cases  in  which  joint  disease  of  a  tuberculous  type  has  fol- 
lowed injury  in  children  whose  family  histories  were  exceptionally  good. 

Konig  estimates  half  the  cases  as  traumatic ;  Albrecht,  one-sixth ; 
Croft,  35  per  cent ;  Gibney,  42  per  cent  (of  which  72  per  cent  were  also 
hereditary);  0.  F.  Taylor,  53  per  cent  (in  845  cases).  Gibney  observed 
845  cases  of  spinal  paralysis  (a  class  of  children  subject  to  constant  falls 
and  injuries),  for  several  years,  and  found  only  four  complicated  with 
joint  troubles.  Roser  observed  100  children  at  Marburg  with  fracture 
of  the  elbow,  and  in  no  case  did  tuberculous  disease  follow. 

In  certain  cases  traumatism  alone  must  be  accepted  as  the  causative 
factor,  while  in  some  cases  no  cause  can  be  assigned. 

The  exanthemata  must  be  mentioned  as  being  the  cause  of  tuberculous 
joint  disease  in  a  certain  proportion  of  cases,  probably  a  larger  proportion 
than  has  been  suspected.  Measles  and  scarlet  fever  are  the  most  com- 
mon eruptive  diseases  to  be  followed  by  these  sequela?.  Croft  estimates 
that  about  seven  per  cent  of  chronic  tuberculous  joint  disease  in  children 
follows  the  exanthemata,  but  there  are  very  few  figures  bearing  upon  the 
subject.  The  effect  of  the  exanthemata  in  causing  other  forms  of  joint 
disease  will  be  alluded  to  later. 

The  entrance  of  the  bacilli  is  apparently  most  often  through  the  re- 
spiratory and  digestive  tracts. 

It  is  probable  that  whatever  continuously  diminishes  the  power  of 
resistance  and  of  repair  in  growing  children  increases  what  may  be 
termed  the  vulnerability  of  the  epiphyses,  and  furnishes  the  soil  for  the 
development  of  tubercle  bacilli  and  the  consequent  results. 

Age. — Tuberculous  joint  disease  is  pre-eminently  a  disease  of  child- 
hood. It  is  rarely,  if  ever,  congenital,'  and  under  one  year  it  is  not 
common.  Of  Gibney' s  860  cases,  so  often  alluded  to,  84.5  per  cent  of 
all  cases  occured  before  fourteen.  Of  619  cases  of  hip  disease  tabulated 
by  Mr.  Wright,2  there  were  under  ten  years  150  cases;  under  fifteen 
years,  279. 

Bryant  tabulated  360  cases,  finding  223  cases  under  the  age  of  ten. 

Taking  Wright's  and  Bryant's  cases,  and  adding  365  others  reported 
by  Say  re, 3  there  are  1,344  cases  of  hip  disease,  of  which  1,000  occurred 
under  fifteen  years  of  age. 

This  is  natural  enough,  for  tuberculous  disease  affects  chiefly  the  epi- 
physis, and  the  epiphysis  during  its  period  of  greatest  activity  when  its 
blood  supply  is  largest  and  its  tissue  changes  are  most  rapid.  More- 
over, children  are  especially  subject  to  falls  and  are  not  so  easily  kept 
quiet  as  adults  are  after  injuries. 

'N.   M.   Shaffer:   "Am.   Clin.  Lectures,"  vol.   iii.,  141  j-  Sonnenberg :    Arch.  f. 
klin.  Chir.,  1881.  xxvi..  789;  Lannelongue:  Loc.  cit. 
2 "Hip  Disease  in  Childhood,"  p.  2. 
;;L.  A.  Sayre  .  "Orthopedic  Surgery  and  Diseases  of  Joints." 


THE   ETIOLOGY   OF   CHRONIC   JOINT   DISEASE. 


is; 


The  records  of  the  New  York  Orthopedic  Dispensary  show  the  liability 
at  different  ages  in  the  cases  of  joint  diseases  of  the  lower  extremity 
treated  for  the  years  1884-86 : 


Under  3. 

3  to  5. 

5  to  lit. 

Hi  to  15. 

110 
28 
18 

15  u,  20. 

Over  20. 

Hip 

115 
43 

12 

316 
69 
18 

509 
94 
24 

47. 

22 

4 

51 

Knee 

63 

Ankle 

7 

Total 

170 

403 

627 

186 

73 

121 

But  such  statistics,  as  Cheyne  points  out,  are  not  altogether  reliable. 
More  people  are  alive  at  the  age  of  five  years  than  at  any  later  age,  so 
that  the  tendency  of  such  statistics,  if  uncorrected,  is  to  exaggerate  the 
frequency  of  joint  tuberculosis  in  young  children.  In  various  continen- 
tal cities  investigations  as  to  the  relative  frequency  of  phthisis  at  differ- 
ent ages  have  shown  that  in  later  life  a  relatively  greater  proportion  of 
persons  die  of  phthisis  than  at  the  period  (from  fifteen  to  thirty  years) 
when  it  has  been  supposed  to  be  most  frequent.  If  the  frequency  of 
joint  tuberculosis  at  different  ages  is  investigated,  employing  the  statistics 
of  .persons  alive  at  different  ages,  the  result  is  as  shown  in  the  table  of 
Cheyne  and  Fassbender. 


Age. 

Apparent  frequency, 

ratio  per 
1,000  of  population. 

Real  frequency, 

ratio  per 

1,000  of  population. 

(Cheyne.) 

Real  frequency, 

ratio  per 

1,000  of  population. 

(Fassbender.  > 

i  to    5.  : 

232 

153 

150 

153 

85 

88 

41 

30 

20 

20 

14 

0 

7 

167 

134 

145 

164 

98 

120 

60 

48 

36 

42 

17 

0 

33 

108 

6  ' 
11   ' 

10 

15 

145 
113 

16  ' 

20 

157 

fll   ' 

25 

77 

26  ' 
31  ' 
86  ' 

30 

35 

40 

109 

76 

106 

41   ' 

6Q 

46  ' 
50  ' 

50 

60 

85 
About  60 

60  ' 

70 

«       i2 

70  ' 

80 

"       21 

The  liability  of  the  aged  to  tuberculous  joint  disease  niiist  not  be 
overlooked.  The  fact  that  people  over  sixty  are  more  often  "scrofu- 
lous" than  people  between  thirty  and  fifty  is  noted  by  Sir  James  Paget.1 

The  patients  may  be  seventy-five  or  ninety,  and  cases  of  hip  disease 
present  the  same  pathological  appearances  here  as  in  young  children. 
The  course  of  the  disease  is  more  rapid  and  destructive  than  in  the 
young,  and  its  etiological  relations  are  decidedly  more  obscure. 


"Clinical  Lectures  and  Essays.     Senile  Scrofula."  2d  ed..  p.  345. 


184 


ORTHOPEDIC    SURGERY. 


The  reasons  given  why  tuberculous  joint  disease  affects  children  to  30 
great  an  extent  are  as  follows  : 

In  the  active  period  of  growth  more  change  is  going  on  and  there- 
fore more  instability  exists  and  consequently  greater  liability  to  disease. 
Children  are  more  liable  to  falls  and  injuries,  which  are  such  a  fertile 
source  of  joint  and  bone  lesions.  It  is  not  till  after  puberty  that  the 
process  of  natural  selection  has  eliminated  the  weaklings  from  the  stock. 
Children  are  kept  quiet  less  easily  than  adults,  and  a  slight  injury  may  de- 
velop into  a  formidable  disease.  Tuberculosis  in  general  is  common  in 
childhood. 

Sex  is  not  a  factor  of  any  prominence,  but  there  is  a  slightly  larger 
proportion  of  tuberculous  joint  disease  among  boys  than  among  girls.  Of 
619  cases  of  hip  disease  collected  by  Wright,  there  were  371  males. 
Holt,1  in  2,307  cases  of  hip  disease  found  1,178  males  and  1,129 
females,  but  the  preponderance  is  very  slight.  Cheyne  in  386  patients 
found  65  per  cent  of  males  and  35  per  cent  of  females. 

Distribution  of  Chronic  Tuberculous  Joint  Disease. — The  relative  fre- 
quency with  which  tuberculosis  attacks  the  various  joints  may  be  esti- 
mated from  the  following  figures : 

At  the  Children's  Hospital,  from  1869  to  1893,  3,820  cases  of  tuber- 
culosis of  the  joints  were  distributed  as  follows:  Vertebrae,  1,964;  hip, 
1,402;  ankle,  300;  knee,  104;  wrist,  20;  shoulder,  15;  elbow,  15.  These 
practically  all  occurred  in  children  under  the  age  of  twelve. 

In  211  cases  of  joint  tuberculosis  among  the  out-patients  occurring  in 
children  under  two  years  there  were  120  cases  of  Pott's  disease,  61  of 
hip  disease,  and  29  of  tuberculosis  of  the  knee-joint: a 


Gibney,  614  cases 
mostly  in  children. 

N.  Y.  Orthopedic 
Dispensary. 

Cheyne,  cases 
under  10  years. 

Spine  

2C9 

271 

103 

31 

1,024 

1,178 

319 

83 
11 
11 

7 

78 

Hip 

44 

Knee 

24 

Ankle 

Shoulder  .' 

4 

2 

Elbow 

13 

Wrist 

2 

Cheyne  added  601  cases  of  tuberculous  joint  disease  of  his  own  to 
those  of  Jaffe,  Schmalfuss,  Billroth,  and  Menzel,  and  found  the  relative 
percentage  to  be  as  follows:  Spine,  23.2  per  cent;  hip,  14.6  percent; 
knee,  16.5  percent;  tarsus  and  ankle,  14.4  percent;  shoulder,  1.5  per 
cent;  elbow,  6.3  per  cent;  wrist  and  hand,  6  per  cent. 

It  will  be  seen  that  although  the  figures  from  American  sources  agree 
fairly  well  with  each  other,  those  from  European  sources  show  a  differ- 


1  Gibney  :  Loc.  cit.,  p.  206. 


-  Thorndike  :  Orth.  Trans.,  ix.,  p.  196. 


CHRONIC   JOINT   DISEASE.  1  35 

ence  in  the  relative  frequency  with  which  joints  are  affected,  possibly 
because  more  adult  cases  are  included  in  the  latter. 

Judsoir  has  called  attention  to  the  great  preponderance  of  joint  dis- 
ease in  the  lower  extremity  as  contrasted  with  the  upper  limb.  Analyz- 
ing the  reports  of  two  orthopedic  institutions  in  New  York  City  he  finds 
that  in  a  single  year  the  following  number  of  cases  of  disease  of  the 
different  joints  were  treated: 

Hip-joint  disease 577 

Knee-joint  disease 18] 

Shoulder  disease , 6 

Elbow  disease 8 

or  758  patients  had  disease  of  the  joints  of  the  lower  extremity,  while  in 
the  same  time  there  appeared  only  14  cases  of  joint  disease  in  the  upper 
extremity. 

In  joint  disease,  when  one  or  more  articulations  are  involved,  any 
combination  may  be  found ;  but  the  most  common  are  hip  disease  and 
Pott's  disease,  knee  disease  and  Pott's  disease,  and  double  hip  disease. 
Disease  of  both  the  knee-  and  hip-joints  is  not  common,  and  double  tumor 
albus  is  unusual. 

Acute  Infectious  Osteomyelitis. 

This  is  a  process  attacking  the  marrow  of  the  bones,  and  secondarily 
affecting  the  joints  if  the  process  reaches  or  originates  in  the  end  of  the 
bone  rather  than  in  the  shaft.  It  is  probably  the  cause  of  many,  if  not 
most,  cases  described  under  the  name  of  "acute  arthritis  of  infants." 
Acute  osteomyelitis  is  a  distinctly  infectious  process,  sometimes  limited 
to  the  marrow  and  sometimes  involving  the  entire  structure  of  the  bone 
including  the  periosteum.  Its  onset  is  sudden,  its  manifestations  are 
severe.  Traumatism  must  be  recognized  as  one  exciting  cause.3  The 
disease  belongs  to  the  group  of  septic  pyaemias  (Ziegler). 

The  bacteria  most  frequently  found  are  staphylococci  and  streptococci, 
alone  or  in  combination.  Other  bacteria  occurring  are  those  of  pneu- 
monia and  typhoid,  and  the  colon  bacillus. 

In  71  cases  of  the  "acute  arthritis  of  infants  due  to  osteomyelitis," 
described  by  Townsend,  20  were  less  than  four  weeks  old,  10  were  less 
than  eight  weeks,  and  6  were  in  their  third  month.  In  27  cases  analyzed 
by  Howard  Marsh  the  hip  was  attacked  14  times,  the  knee  11,  the  shoul- 
der 5,  the  ankle  4,  the  elbow  4,  and  the  wrist  once.  Of  the  27  cases  20 
Were  monarticular. 

Osteomyelitis  begins  as  a  hyperemia  of  the  bone  marrow  with  pos- 
sibly hemorrhagic  infiltration.     Later  suppurative  foci  of  a  dull  yellow 

1  N.  Y.  Med.  Record,  May  18th,  1889.       -  Gebele  :  Inaug.  Diss.,  Munich,  1897. 


1S6  ORTHOPEDIC   SURGERY. 

or  grayish  color  appear,  while  in  severe  cases  the  entire  marrow  becomes 
purulent,  and  the  Haversian  canals  of  the  cortical  portion  become  filled 
with  pus.  There  are  cases  in  which  infection  occurs,  but  absorption  takes 
place  before  the  occurrence  of  suppuration.  Metastatic  abscesses  and 
thrombosis  of  the  veins  of  the  marrow  may  follow. 

If  the  inflammation  reaches  the  epiphyseal  cartilage  in  young  patients 
separation  of  the  epiphysis  is  likely  to  occur.  In  the  hip-joint  this  leads 
to  a  lax  condition  of  the  joint,  simulating  congenital  dislocation  of  the 
hip. 

Metastatic  inflammation  of  bone, '  which  may  occur  in  pyoeniia, 
typhoid,  scarlet  fever,  and  measles,  may  follow  a  clinical  course  similar 
to  that  described  above.  Usually  the  foci  are  smaller  and  destruction  is 
less  extensive. 

If  the  infecting  process  enters  the  joint  the  inflammatory  process  be- 
comes severe  and  destructive,  cartilage  is  softened  and  destroyed,  and  an 
abscess  of  rapid  appearance  is  the  usual  clinical  manifestation. 

Osteomyelitis  may,  however,  be  the  cause  not  only  of  a  suppurative 
but  of  a  simple  joint  inflammation  at  times,  due  to  the  contiguity  of  the 
bone  inflammation.'- 

In  acute  osteomyelitis  the  clinical  symptoms  are  those  of  a  very  severe 
constitutional  disturbance  attended  with  high  fever,  chills,  severe  pain, 
and  rapid  exhaustion. 

The  prognosis  depends  in  large  measure  on  early  operative  inter- 
ference. Ankylosis  is  likely  to  result  from  the  process,  as  are  also  dis- 
locations, subluxations,  and  distortion  when  the  joints  are  involved. 
Epiphyseal  separation  must  be  watched  for  throughout. 

The  entrance  of  the  organisms  in  young  infants  is  probably  through 
the  umbilicus  or  pharynx.  In  older  persons  the  germs  probably  enter 
through  some  abrasion  or  by  the  pharynx,  tonsils,  or  alimentary  canal. 

Free  incision,  washing,  and  drainage  at  the  earliest  possible  period  is 
the  only  treatment  to  be  considered. 3  # 

'Swoboda:  Wien.  klin.  Woch.,  1897. 

2  Garret  Brans'  Beit.  z.  klin.  Chir.,  xi.,  1894,  797. 

3Rovsing:  Langenbeck's  Archiv,  Bd.  liii.,  Heft  3;  Herzog :  Munch,  med. 
Wociien.,  1898,  No.  14,  410;  Still:  Clin.  Jour.,  1898,388;  Griffiths:  Jour.  Path, 
and  Bact.,  1896-97,327;  Eve:  Clin.  Jour.,  1897,  x.,  385;  Kasparek :  Baumgarten's 
Jahresber.,  1895;  Braquehaye:  Gaz.  de  M£d.  et  de  Chir.,  1895,  p.  199;  Smith:  St. 
Barth.  Rep.,  1874;  Baker:  Lancet,  1880;  Wright:  Lancet,  1881,  July  23d,  127; 
Krause:  Arch.  f.  klin.  Chir.,  1889,  477;  Battle:  Trans.  Path.  Soc,  London,  1891; 
Gerard  Marchant :  Bull.  Soc.  Anat.,  F6vrier,  1889,  p.  151;  Alibert:  Gaz.  hebd.  de 
MM.  et  de  Chir.,  1894,  p.  254;  Lannelongue  et  Achard  :  Ann.  Inst.  Pasteur,  1891  ; 
Koplik  and  Van  Arsdale :  Am.  Jour.  Med.  Sciences,  1892;  Mauclaire:  Des  Arth. 
suppurees  dans  les  Mai.  infect.,  Arch.  g£n.  de  M£d.,  1895,  January;  Dardenne  :  Th. 
de  Toulouse.  1894. 


CHRONIC    JOINT   DISEASE.  L87 


Simple  Ostitis. 

Simple  or  traumatic  ostitis  secondarily  affecting  the  joints  is  very  un- 
usual. In  the  traumatic  form,  one  finds  blood  effused  and  inflammatory 
processes  beginning,  of  the  kind  described  above  as  typical,  the  peri- 
osteum is  infiltrated,  and  the  bone  marrow  filled  with  a  fluid  cellular 
exudation.  Then  it  depends  upon  circumstances  whether  absorption  will 
take  place  or  whether  pus  formation  will  begin,  and  the  trabecular  will 
be  absorbed  and  the  bone  broken  down,  or  whether  the  whole  affair  will 
take  on  th#tuberculous  type  and  run  the  course  of  that  affection.  If 
no  infection  comes,  wounds,  tears  of  the  joint  capsule,  fractures,  etc., 
result  in  only  a  serous  or  fibrinous  or  bloody  effusion  into  bone,  joint, 
and  capsule;  but  when  the  bone  is  infected,  suppuration  and  destruc- 
tion may  occur. 

Tumors  of  the  Bones  Involving  the  Joints. 

Primary  tumors  of  bone  belong  to  the  group  of  connective-tissue  tu- 
mors. The  periosteum  and  bone  marrow  form  the  matrix  for  their  devel- 
opment. These  tumors  correspond  to  the  various  types  of  connective  tis- 
sue, fibrous,  mucoid,  cartilaginous  and  osseous.  Among  primary  tumors 
are  to  be  classed  sarcomata.  Secondary  tumors  of  any  kind  may  occur, 
among  the  latter  being  carcinoma.  Angioma,  hematoma,  echinococcus 
cyst,  and  aneurism  must  be  mentioned  as  other  possibilities. 

Exostoses. — Apart  from  the  changes  of  arthritis  deformans  there 
sometimes  occur  exostoses  about  the  articular  ends  of  the  bones,  which 
are  very  rarely  large  enough  to  impede  the  motion  of  the  joints ;  at  other 
times  they  are  troublesome  by  involving  tendons  in  their  growth. 

They  are  of  two  kinds.  First,  small  spur-like  processes  or  rounded 
projections,  the  result  either  of  an  inflammatory  process  or  of  a  simple 
hypertrophy;  and  several  large  lobulated,  spongy  masses  of  bone  called 
diffused  osteoid  tumors,  which  occasionally  involve  and  destroy  a  joint, 
as  in  the  cases  of  Paget  and  Lancereaux,  in  which  the  knee-joint  was  so 
badly  involved  by  the  growth  of  one  of  these  osteoid  tumors  from  the 
tibia  and  femur  that  amputation  was  necessary. 

Cartilaginous  exostoses  in  the  neighborhood  of  the  joints  have  occa- 
sionally a  capsule  overlying  the  layer  of  cartilage  corresponding  in  struc- 
ture to  synovial  membrane.  This  condition  is  spoken  of  as  a  bursate  ex- 
ostosis (Ziegler). 

Chondromata  grow  most  frequently  from  the  bones  of  the  hand. 
They  are  often  multiple,  occur  most  often  in  children  and  young  adults, 
and  may  be  congenital.     Myxomata  and  lipomata  are  rare  in  the  bones. 

Sarcomata  originate  in  the  marrow  or  periosteum.     If  they  contain 


188  ORTHOPEDIC    SURGERY. 

bony  tissue  they  are  spoken  of  as  osteosarcomata.  Joint  sarcomata  affect 
chiefly  young  subjects  from  fifteen  to  twenty -five  years  old,  and  the  joints 
commonly  affected  are  the  knee,  shoulder,  and  wrist.  Of  70  cases  of 
giant-celled  sarcoma  analyzed  by  Gross  21  were  in  the  femur  (17  in  the 
lower  epiphysis),  and  28  in  the  upper  epiphysis  of  the  tibia  and  fibula. 
Central  sarcomata  are  more  likely  to  invade  joints  than  are  the  periosteal 
growths.  Males  are  slightly  more  liable  than  females  to  be  affected,  87 
out  of  149  cases  being  in  men. 

Carcinoma  of  bone  may  occur  secondarily  from  extension  or  metasta- 
sis. It  occurs  in  circumscribed  nodes  or  as  a  diffuse  infiltration.  The 
latter  is  usually  accompanied  by  proliferation  of  the  periosteum  and  ab- 
sorption of  the  substance  of  the  bone.  This  is  at  times  replaced  by  soft 
new  bone,  and  a  condition  may  be  present  resembling  locally  osteomalacia 
and  known  as  carcinomatous  osteomalacia. 

With  this  form  as  with  primary  new  growths  spontaneous  fracture 
may  occur. 

III.   Joint  Diseases  in  Constitutional  Affections. 

Certain  constitutional  affections  are  attended  by  joint  manifestations. 
The  remaining  affections  of  the  joints  will  be  considered  under  etiological 
rather  than  pathological  headings. 

The  principal  affections  accompanied  by  joint  manifestations  are : 

I.  Syphilis. 

II.  Arthritis  deformans. 

III.  Kheumatism. 

IV.  Gout. 

V.  Acute  infectious  diseases. 

VI.  Gonorrhoea. 

VII.  Pathological  conditions  of  the  nervous  system. 

VIII.  Haemophilia,  scurvy,  etc. 

I.   Syphilis. 

Acquired  syphilis  has  certain  joint  manifestations. 

Arthralgia  without  objective  symptoms  may  occur  early  in  the  second- 
ary stage. 

Simple  serous  synovitis,  associated  with  pain,  redness,  and  swelling, 
may  accompany  the  secondary  symptoms.  This  condition  may  pass  on 
to  a  chronic  hydrops. 

In  the  tertiary  stage  chronic  serous  synovitis  may  be  present.  It  is 
slow  in  progress,  generally  accompanied  by  considerable  effusion  and 
much  thickening  of  the  capsule  which  may  later  contract  and  cause 
fibrous    ankylosis.     This  thickening    of   the   capsule  may  be  due  to  a 


CHRONIC    .JOINT    DISK  ASK.  L89 

chronic  hyperplastic  inflammation  of  the  capsule  (Finger)  or  to  a  gumma- 
tous infiltration  of  the  subsynovial  tissue  (Richet,  Lanceraux).  There 
is  generally  a  development  of  the  tufts  in  the  severer  cases  along  with 
some  destruction  of  cartilage,  and  perhaps  the  formation  of  osteophytes. 

These  and  other  processes  may  be  the  result  of  gummata  of  the  ends 
of  the  bones  or  in  the  periosteum  or  situated  about  the  joints,  not  neces- 
sarily in  any  intimate  connection. 

Gummatous  ostitis  is  a  cause  of  secondary  affections  of  the  joints 
when  situated  in  their  neighborhood.  On  section  the  bone  shows,  most 
often  in  the  periphery,  a  yellowish-gray  focus  of  disease,  in  appearance 
strikingly  like  the  early  stage  of  focal  tuberculosis.  But  from  this  latter 
it  may  be  distinguished  by  the  absence  of  any  surrounding  hypereemia  or 
infiltration,  which  goes  with  tuberculous  disease.  Often,  of  course,  these 
gummata  exist  along  with  much  synovitis  of  a  characteristic  type,  and  a 
much  thickened  and  diseased  periosteum.  Gummata  in  the  periosteum 
appear  as  elastic  swellings,  rich  in  fluid,  poor  in  cell  elements ;  later  they 
degenerate  to  material  like  pus  and  by  fatty  degeneration  and  absorption 
to  a  cheese-like  substance  and  scar-tissue,  and  finally  only  a  thickening 
remains. 

Secondarily  to  these  periosteal  and  bone  lesions  come  the  capsular 
and  synovial  thickening,  and  the  cartilage  degeneration. 

Jullien  has  estimated  that  28  per  cent  of  all  cases  of  tertiary  syphilis 
develop  bone  lesions,  while  Gottheil  in  248  cases  of  tertiary  syphilis 
found  only  13  cases  of  bone  disease. ' 

Hereditary  syphilis  is  proportionately  more  often  attended  by  joint 
complications  than  is  acquired  syphilis. 

Guterbock 2  estimates  that  arthritis  occurs  in  one  case  in  three  hundred 
of  hereditary  syphilis  in  children  under  five  years.  Arthralgia  is  rare 
and  acute  synovitis  is  rare  (Pielicke3)  or  absent  (Kirmisson  and  Jacobson4). 

Chronic  serous  synovitis  has  been  described  by  Clutton,  although 
such  cases  may  be  due  to  bone  lesions  (Fournier) .  The  type  described 
by  Clutton  occurs  in  children  from  eight  to  fifteen  years  as  a  symmetrical 
swelling  of  the  knees  accompanied  by  little  pain  or  limitation  or  motion. 
The  capsule  may  be  thickened,  and  the  effusion  is  generally  moderate  in 
amount. 

The  most  characteristic  form  of  joint  disease  in  hereditary  syphilis  m 
children  is  the  osteochondritis  of  Parrot.  This  consists  in  a  broadening 
of  the  cartilaginous  layer  of  the  epiphysis  next  to  the  diaphysis  with 
irregularity  of  the  zone  of  ossification.  At  the  same  time  there  occur 
thickening  of  the  epiphysis  and  a  growth  of  granulation  tissue,  sometimes 
breaking  down  in  the  medullary  cavity.  As  a  result  of  this  process 
separation  of  the  epiphysis  may  occur  spontaneously  or  as  the  result  of 

JN.  Y.  Med.  Jour.,  February  4th,  1899.      2Berl.  klin.  Wochenschr.,  1884,  442. 
3 Lancet,  1886,  i.,  391.         4Deutsch.  Chir.,  Lief.  66,  p.  294. 


190  ORTHOPEDIC   SURGERY. 

some  trauma.  Secondary  synovitis  is  likely  to  accompany  this  process. 
This  may  be  of  any  character  and  is  often  purulent,  and  the  cartilage 
may  degenerate  and  soften.  Suppuration  in  general  is  less  rare  in  hered- 
itary than  in  acquired  syphilis. 

The  clinical  symptoms  of  this  osteochondritis  are  thickening  of  bone, 
tenderness,  and  joint  inflammation,  secondarily  with  lameness  and  even 
uselessness  of  the  limb  for  a  time.  The  affection  is  sometimes  spoken 
of  as  syphilitic  pseudoparalysis  of  infants. 

Later  hereditary  syphilis  may  show  a  somewhat  similar  affection  due 
to  overgrowth  of  the  epiphysis,  and  spoken  of  as  "chronic  osteo-arthrop- 
athy  of  hereditary  syphilis"  or  "false  tumor  albus."  The  thickened 
and  deformed  epiphyses  form  a  mass  which  appears  as  a  spindle-shaped 
swelling  (most  often  at  the  knee).  There  is  typically  no  muscular 
spasm,  although  marked  atrophy  of  the  muscles  is  present.  Pain  is 
generally  absent,  although  rarely  there  may  be  some  tenderness  and  local 
heat.  What  inflammation  of  the  joint  is  present  is  secondary  and  not 
characteristic.  It  is  favorably  affected  by  the  usual  treatment  for 
syphilis.  * 

II.   Arthritis  Deformans. 

This  affection  is  known  by  a  multiplicity  of  names,  of  which  the 
following  are  the  principal  ones :  Rheumatic  gout,  chronic  rheumatic  ar- 
thritis, arthrite  seche,  arthritis  deformans,  osteo-arthritis,  nodosity  of  the 
joints,  rheumatoid  arthritis,  nodular  rheumatism,  dry  arthritis,  proliferat- 
ing arthritis,  malum  senile,  chronic  articular  rheumatism.  The  name 
arthritis  deformans  will  be  adopted  here,  inasmuch  as  it  describes  the 
condition  and  involves  no  etiological  theory. 

The  process  is  characterized  by  a  hyperplastic  proliferation  along 
with  degenerative  changes  in  cartilage  and  bones. 

Extensive  softening  of  the  cartilage  occurs  along  with  the  formation 
of  cavities  in  the  deeper  layer  next  to  the  bone.  These  cavities  are  later 
lined  with  vascular  medullary  tissue  from  the  bone.  The  cartilage  be- 
tween these'  cavities  is  generally  converted  into  osteoid  tissue  and  bone. 


1  White  and  Martin  :  "  Genito-Urin.  and  Ven.  Diseases  ;  "  Kirmisson  and  Jacob- 
son  :  Rev.  d'Orth.,  November,  1897,  p.  446;  Sonnenburg :  Berl.  klin.  Wochenschr. , 
1884,  S.  548;  Finger:  "Syph.  u.  d.  vener.  Krankh.,"  1896,  S.  114;  Taylor-  "Vener. 
Diseases;"  Renard:  Rev.  d'Orth.,  1893,  No.  3,  p.  187,  Bosher :  "Am.  Text-book 
Gen.  Urin.  Diseases,  Syph.,  and  Dis.  of  Skin,"  p.  661;  Danlos :  Ann.  d.  Derm,  et 
de  Syphilig.,  1896,  vii.,  1322;  Anderson:  Glasgow  Med.  Jour.,  1896,  xlvi.,  p.  9; 
Schuller:  Beilage  z.  Centralbl.  f.  Chir.,  1882,  p.  31;  ibid.,  p.  32;  Pielicke :  Berl. 
klin.  Wochenschr.,  1898,  p.  78;  Baginsky :  Berl.  klin.  Wochenschr.,  1894,  548; 
Henoch:  Berl.  klin.  Wochenschr.,  1884,  548;  Hirschberg :  Ibid.,  548;  Landerer: 
Berl.  klin.  Wochenschr.,  1884,  757;  Virchow.  Berl.  klin.  Wochenschr.,  1884,  534. 


CHRONIC   JOINT   DISEASE.  L91 

The  changes  in  the  cartilage  are  of  the  usual  type  of  cartilage  inflam- 
mation, only  more  severe.  The  hyaline  substance  becomes  fibri Hated, 
and  where  there  is  pressure  it  is  worn  away  in  small  patches  or  large 
surfaces,  exposing  the  bony  lamella. 

The  changes  in  the  bones  are  in  the  first  instance  the  result  of  the 
wearing  away  of  the  cartilage  covering  the  ends.  This  irritation  results 
in  hyperemia  which  is  attended  by  a  slight  degree  of  rarefying  ostitis. 

After  the  enlargement  of  the  Haversian  canals  and  the  degeneration 
of  the  bone  cells,  a  formative  activity  springs  up  in  the  periosteum  and 
in  the  endosteum  covering  the  cancellous  walls,  and  a  compact,  "  ebur- 
nated  "  layer  is  quickly  made  which  covers  the  exposed  end,  under  which 
layer  a  formative  activity  is  goifig  on  while  the  polished  surface  is  always 
being  worn  away ;  and  to  this  constant  wearing  away  is  due  the  "  worm- 
eaten  "  appearance  so  generally  spoken  of,  which  is  due  to  the  exposing 
of  the  ends  of  the  Haversian  canals. 

The  subchondral  marrow  frequently  loses  much  of  its  fat  and  cysts 
may  form  in  it,  which  may  be  exposed  if  the  overlying  bone  is  worn 
away. 

But  while  pressure  and  friction  are  wearing  away  the  centre  of  the 
articular  ends  of  the  bones,  the  margins  are  rapidly  proliferating.  The 
same  process  of  cartilage  degeneration  taking  place  at  the  periphery  of 
the  joints  results  differently.  There  is  sufficient  freedom  from  pressure 
not  to  wear  away  the  degenerated  substance,  and  the  edge  of  the  syno- 
vial membrane  retains  the  proliferated  corpuscle  cells,  which  remain, 
and,  taking  on  a  formative  activity,  make  the  marginal  hypertrophies  or 
ecchondroses.  The  hypertrophic  bony  enlargement  is  closely  bound  up 
with  the  development  and  increase  of  these  marginal  ecchondroses. 
These  lumps  internally  are  bony,  superficially  they  are  cartilaginous. 
Sometimes  these  perforate  the  synovial  membrane  and  become  intra- 
articular, and  often  break  off  to  form  loose  bodies;  at  other  times  they 
grow  laterally,  and  do  not  encroach  upon  the  joint,  but  form  a  buttress- 
like growth  which  speedily  restricts  the  motion  of  the  joint,  although 
true  ankylosis  rarely  or  never  takes  place,  the  stiffness  and  loss  of  joint 
movement  being  due  to  this  ensheathing  bony  growth.  Inasmuch  as 
these  ultimately  ossify,  an  explanation  of  the  extreme  changes  in  the 
shape  of  the  ends  of  the  bones  is  afforded. 

Finally,  at  the  attached  border  of  the  capsule  as  well  as  in  the  liga- 
ments themselves,  there  begins  a  dense  bone  formation  which  contributes 
to  the  ensheathing  bony  mass.  The  osteophytes  are  more  rounded  and 
flat  than  one  is  accustomed  to  see  in  bone  formation  after  fractures,  for 
instance;  and  from  the  fact  that  ossification  is  not  preceded  by  any 
especial  vascularity,  the  new-formed  bone  is  more  dense  and  compact 
than  normal;  the  tissues  ossify  just  as  they  are. 

The  wearing  away  of  the  articular  surface  of  the  bones  may  lead  to 


192  ORTHOPEDIC   SURGERY. 

distortion  of  the  joints.  The  head  of  the  femur  may  completely  disap- 
pear, and  if  new  bone  forms  around  the  periphery  an  entirely  new  head 
may  be  formed  which  is  attached  to  the  shaft  by  little  or  no  neck. 

There  is  a  thickening  of  the  synovial  membrane,  a  hypertrophy  of 
the  fringes,  and  finally  the  development  of  shaggy  surface. 

Synovial  folds  and  villous  fringes  may  increase  until  they  fill  the  joint 
cavity.  When  fat  is  deposited  in  these  the  condition  known  as  "  arbores- 
cent lipoma  "  exists. 

Thickening  of  the  capsule  and  degeneration  of  the  ligaments  may 
occur ;  the  latter  become  inflamed  and  then  thickened,  and  finally  they  de- 
generate into  a  condition  in  which  they  resemble  fibrocartilage  or  elastic 
tissue,  and  in  virtue  of  this,  the  affected  joints  may  show  decided  lateral 
mobility.  The  tendons  and  intracapsular  ligaments  may  disappear  by 
"absorption."  Tendons  may  be  found  adherent  to  the  bone  with  a  part 
of  their  substance  wanting.  The  muscles  controlling  the  joint  atrophy 
from  disease  as  well  as  disuse. 

Arthritis  deformans  is,  clinically,  a  distinct  type,  though  some  cases 
are  hard  to  separate  from  rheumatism.  The  most  usual  form  met  with 
is  the  chronic  polyarticular.  This  attacks  patients  most  often  toward 
middle  life,  but  it  may  occur  in  children  or  in  later  life.  Females  are 
oftener  attacked  than  males.  The  etiology  is  still  uncertain,  but  the 
neuropathic  theory  suggested  by  Mitchell  finds  many  adherents.  Ord 
goes  so  far  as  to  assume  a  cord  lesion.  The  usually  accepted  causation 
by  damp  and  cold  is  at  least  doubtful,  while  the  older  theory  accusing 
gout  and  rheumatism  hardly  finds  adherents  to-day.  Here,  as  in  many 
other  conditions,  bacterial  action  has  been  assumed. 

Schiiller1  described  a  bacillus  occurring  in  the  joints  of  this  affection 
with  relative  regularity.  It  grows  on  ordinary  media.  Injected  into  the 
joints  of  rabbits  it  produced  no  pus  but  remained  in  the  joints,  and  two 
months  after  injection  caused  a  process  similar  to  that  of  arthritis  defor- 
mans in  man.  The  writers  have  not  been  able  to  find  that  this  has  been 
confirmed  by  other  observers. 

Dor,2  by  the  injection  of  an  attenuated  culture  of  staphylococcus  into 
the  joints  of  rabbits,  produced,  after  one  year,  joint  changes  similar  to 
those  of  arthritis  deformans. 

Bannatyne  described  a  small  bipolar-staining  bacillus  existing  in  the 
fluid  of  these  joints,  and  Blaxall 3  confirmed  his  observations.  The  arti- 
cles of  these  two  writers  are  not  convincing,  and  one  competent  observer 
following  Blaxall' s  technique  with  great  care  was  unable  to  find  any 
such  microorganisms. 

Heredity  seems  to  play  some  part  in  the  causation. 

'Berl.  klin.  Wochschr.,  1893,  p.  865. 
sComptes  Rend.  Soc.  de  Biol.,  1893,  p.  899. 
■Lancet,  1896,  i.,  p.  1120. 


CHRONIC    JOINT   DISEASE.  L93 

The  monarticular  forms  are  often  consequent  on  some  trauma  and 
usually  occur  in  older  persons.  The  best  known  variety  is  the  malum 
coxa;  senile.  This  type  differs  from  the  polyarticular  forms  only  in  its 
local  limitation. 

In  young  children  the  clinical  type  differs  somewhat,  as  pointed  out 
by  Still.  This  type  appears  before  the  second  dentition.  It  may  be 
acute  in  onset,  and  females  are  more  often  affected  than  males.  There 
is  some  effusion,  the  capsule  is  thickened,  there  are  degenerative  changes 
in  the  cartilage,  but  no  lipping  or  osteophytes.  There  are  no  subcuta- 
neous "  rheumatic  "  nodules.  The  affection  is  polyarticular.  There  is 
usually  some  enlargement  of  glands  and  spleen.  The  epiphyses  may  be 
hypertrophied. 

Apart  from  this,  arthritis  deformans  of  just  the  type  seen  in  adults 
may,  and  not  infrequently  does,  occur  in  children — in  this  form,  accord- 
ing to  Still,  usually  after  six  years  of  age. 

Morrant  Baker1  describes  a  considerable  series  of  cysts  secondary  to 
rheumatoid  arthritis  and  some  cases  with  fluid  free  without  obvious 
synovial  sac  wall.3 

III.   Rheumatism. 

Rheiunatism  is  an  affection  which  receives  credit  for  the  causation 
of  much  joint  disease  with  which  it  has  really  nothing  to  do.  The  mani- 
festations of  arthritis  deformans  are  confused  with  the  truly  rheumatic 
affections,  and  as  in  simple  acute  synovitis  of  the  knee  in  which  no 
cause  is  assignable,  the  disposition  of  many  practitioners  is  to  consider 
the  affection  as  "rheumatic,"  so  in  joint  disease  in  general  obscure  cases 
are  liable  to  be  placed  in  this  class. 

In  true  rheumatic  joint  affections  the^  structure  attacked  is  chiefly  the 
synovial  membrane,  which  secretes  much  fluid  and  takes  on  a  prolifera- 
tive action  with  enlargement  of  the  synovial  tufts,  a  condition  which  may 
give  rise  to  swelling  of  a  joint  without  necessarily  the  presence  of  much 
effusion.  The  capsule  becomes  thickened,  and  although  even  in  pro- 
longed cases  the  cartilage  is  likely  to  remain  intact,  it  may  become  fibril- 
lated  at  the  edges  and  eroded  in  spots,  while  a  vascular  pannus  spreads 
in  from  the  edges.  The  whole  tendency  is  away  from  suppuration  and 
toward  connective-tissue  formation.  One  form,  which  Schiiller  calls 
arthritis  rheumatica  ankylopoetica,  shows  but  little  or  no  effusion,  but  a 
tendency  to  the  formation  of  fibrous,  and  later  bony,   ankylosis.     This 

'St.  Barth.  Hosp.  Rep.,  vols.  xiii.  and  xxi. 

2"Arthr.  Deform,  in  Children;"  Tschernow:  Cbl.  f.  Chir.  (rei),  1898.  8-53; 
Still:  Clin.  Jour.,  1898,  388;  Osier:  Montreal  Med.  Jour.,  1895-96,  xxiv..  777: 
Wagner:  Munch  med.  Wochenschr. ,  1888,  195;  Delcourt:  Rev.  Mens,  ties  Mai.  de 
l'Enf.,  1898,  329;  Strum  pell  •  "  Lehrb.  d.  spec.  Path.  u.  Ther.,"  1884.  ii.,149;  Pon- 
cet :  Rev.  de  Chir..  1897.  1003  ;  Berard  and  Destot  :  Ibid. 
13 


194  ORTHOPEDIC    SURGERY. 

ordinarily  occurs  in  people  of  lowered  vitality  through  want,  or  use  of 
improper  food.  This  corresponds  to  the  arthritis  pauperum,  ossifying 
arthritis  (Griffiths),  and  polyarthritis  chronica  rheumatica  (Ziegler). 

Kheumatic  joint  affections  attack  oftenest  the  knee,  then  ,the  foot, 
elbow,  hand,  shoulder,  hip,  etc.     They  are  monarticular  or  polyarticular. 

For  the  most  part,  purely  rheumatic  affections  attack  youths  and 
people  of  middle  age. 

The  etiology  of  chronic  rheumatic  joint  disease  is  but  little  under- 
stood. It  may  be  primary  or  secondary  to  acute  attacks.  It  may  follow 
a  depression  in  the  general  condition  or  occur  as  the  result  of  exposure 
or  more  rarely  from  some  injury. 

Certain  cases  of  joint  disease  resembling  tuberculosis  in  all  essential 
characters  except  perhaps  in  the  typical  muscular  spasm,  pursue  such  a 
benign  course  and  are  so  favorably  affected  by  anti-rheumatic  remedies 
that,  especially  in  rheumatic  subjects,  the  conclusion  may  be  warrantable 
that  rheumatism  is  the  cause  of  the  affection. 

IV.   Gout. 

The  joint  affection,  which  is  the  manifestation  of  the  constitutional 
malady  known  as  gout,  ordinarily  begins  as  an  acute  attack,  and  is 
followed  by  a  chronic  inflammatory  process,  increased  by  constant  ex- 
acerbations. The  synovial  membrane  first  presents  the  appearances  of 
acute  inflammation ;  the  cartilage  also  shows  a  tendency  to  inflamma- 
tory degeneration  and  erosion,  and  on  its  free  surface  and  in  its  tissue, 
as  well  as  in  its  capsule  and  periarticular  structures,  there  appears  a  de- 
posit of  acicular  crystals  of  urate  of  soda,  which  localized  deposits  are 
known  as  "tophi."  The  marginal  growths  are  true  exostoses  (Wynne) 
and  not  as  in  arthritis  deformans  covered  by  proliferating  cartilage. 
There  is  a  permanent  thickening  of  the  synovial  membrane.  There  is 
but  little  tendency  to  suppuration,  unless  the  calcareous  deposits  ulcerate 
through  the  skin  by  pressure  and  so  open  the  periarticular  tissue.  The 
common  seat  of  the  affection  is  the  metatarso-phalangeal  joint  of  the 
great  toe  (podagra).  The  joints  of  the  hands,  and  the  knee-  and  elbow- 
joints  are  also  often  affected. 

V.   Acute  Infectious  Diseases. 

The  acute  infectious  diseases  in  which  joint  complications  may  occur 
are  as  follows1 :  Measles,  scarlet  fever,  smallpox,  typhus  fever,  typhoid 

1  Fournier  et  Courmont :  Rev.  de.  MM.,  xvii.,  1897,  681 ;  Perutz  :  Miinch.  med. 
Wochenschr.,  1898,  S.  80;  Fernet:  Gaz.  des  Hop.,  1897,  1246;  Vogelius  10  (ref. 
Virchow's  2.  H.  Jaliresber.)  ;  Muhsam :  Berliner  klin.  Wochenschr.,  1897,  855; 
Brunner:  Correspondenzbl.  f.  Schweizer  Aerzte,  xxii.,  1892,  No.  12. 


CHRONIC   JOINT   DISEASE.  L95 

fever,1  cerebrospinal  meningitis,3  gonorrhoea,  pneumonia,  dysentery/ 
diphtheria,  erysipelas,  epidemic  parotitis,'  pertussis,  puerperal  fever, 
pyaemia,  septicaemia,  glanders,5  after  the  use  of  catheters  and  sounds, 
and  possibly  in  malaria. 

The  lesions  occurring  are  now  almost  universally  attributed  to  the 
presence  in  the  joints  of  microorganisms,  most  often  of  the  species  caus- 
ing the  primary  disease.  The  infection  of  the  joint  ordinarily  is  by  way 
of  the  circulation,  but  it  may  extend  directly  or  by  lymph  channels  from 
some  separate  focus  of  disease  (as  in  puerperal  fever,  acute  osteomyelitis, 
or  erysipelas). 

The  joints  may  develop  an  acute  or  a  chronic  process,  serous  or  puru- 
lent. Nearly  always  the  infection  seems  to  be  a  synovial  one,  and  even 
in  severe  forms  the  bony  structures  are  usually  but  little  affected.  The 
pathological  condition  varies  little  with  the  special  infection.  There 
may  be  fibrino-purulent  false  membrane  as  a  result  of  deposit  and  exuda- 
tion. Still  later  there  is  suppuration  of  the  synovial  membrane,  with 
loss  of  epithelium  and  formation  of  granulation  tissue,  fibrous  degenera- 
tion, or  even  necrosis  of  the  cartilages,  damage  to  the  bone  ends,  and 
destruction  of  the  ligaments.  Spontaneous  luxations  may  occur.  In  a 
great  part  of  the  cases,  however,  the  local  infective  process  runs  its 
course  without  great  damage,  and  even  with  suppurative  cases  early  in- 
cision is  usually  resorted  to  before  the  process  has  accomplished  much 
destruction. 


1  Ashby  :  Brit.  Med.  Jour.,  1886,  i.,  970  ;  Hodges  :  Lancet,  1894,  ii.,  1195  ;  Bokai  ; 
Jahrb.  f.  Kinderheilk. ,  1885,  xxiii.,  305;  Garrod,  Archibald:  "A  Treatise  on  Rheu- 
matism," 1890;  Quoted  in  Smith  and  Sturge,  Lancet,  1895,  ii.,  1212;  Spiers:  Mon- 
treal Med.  Jour.,  April,  1894;  Thomas:  Ziemssen's  Cyclop.;  Hay  ward :  Quain'.s 
Diet.  Med.,  cited  by  Hodges;  Henoch:  Lect.  Children's  Dis.,  Syd.  Soc.  Tran.,  ii., 
210  (cited  by  Smith  and  Sturge)  ;  McKenzie  :  Canad.  Practit.,  January,  1893;  Rum- 
mer :  Rev.  de  Chir.,  1898,  55  ;  Ann.  Surg.,  xiv.,  483  ;  De  Loupersonne  :  "Les  Arthrites 
Infect.,"  Paris,  1886. 

2  Griffiths:  Jour.  Path,  and  Bact.,  1896-97,  p.  327;  Herzog:  Munch,  med. 
Wochenschr.,  1898,  p.  416;  Eve:  Clin.  Jour.,  1897,  x.,  305. 

3Keen:  "The  Surgical  Complications  of  Typhoid  Fever";  Miihsam  :  Berl.  klin. 
Wochenschr.,  1897,  855;  Sainton:  Rev.  d'Orth.,  1892,  355;  Rummer :  Rev.  d.  Chir. 
1898,  55. 

4 Osier:  "Practice  of  Med.,"  p.  106  (1898  edit.)  ;  Boston  Med.  and  Surg.  Jour., 
1898.  exxxix.,  641;  Eronz :  Wiener  klin.  Wochenschr.,  1897,  x.,  15;  Councilman, 
Mallory,  and  Wright :  Rep.  State  Board  of  Health  of  Massachusetts,  1898. 

5  Morel:  Gaz.  hebd.  de  Med.  et  de  Chirurgie,  May  8th,  1898;  Ziegler:  "Path. 
Anatomie,"  Bd.  ii.,  159 ;  Herman  and  Hertwig :  Cited  by  Garrod  (loc.  cit.) ;  Huette  . 
Arch.  gen.  de  MeU,  1869,  Series  vi.,  vol.  xiv.,  129  (quoted  by  Garrod);  Thomas  (of 
Tours) :    (Cited  by  Garrod) ;  Revue  de  Medecine,  1885,  p.  192. 


196  ORTHOPEDIC   SURGERY. 


YI.   Gonorrhoea. 

Gonorrhceal  arthritis  or  gonorrhoeal  rheumatism  are  the  names  most 
commonly  applied  to  an  inflammation  of  the  joints  occurring  in  the  later 
stages  of  gonorrhoea. 

This  inflammation  follows  no  definite  type ;  it  is  acute  or  chronic,  and 
is  most  often  polyarticular.  Of  251  cases  investigated  by  Northrup  50 
only  affected  one  joint;  20,  two  joints;  175,  three  or  more  joints.1  In 
41  cases  collected  by  Miihsam  30  were  monarticular.  In  348  cases  col- 
lected by  Jullien  143  were  monarticular. 

The  commonest  inflammations  are  as  follows : 

Arthralgia,  without  definite  lesions  or  associated  with  slight  peri- 
articular lesions  or  bursitis. 

Acute  synovitis,  monarticular  or  polyarticular,  resembling  acute  rheu- 
matism, with  considerable  periarticular  swelling. 

Periarticular  inflammation  with  joint  effusion  absent  or  subordinate. 

Tenosynovitis  occurring  about  the  joints,  but  not  necessarily  involving 
them. 

Chronic  synovitis,  serous  or  purulent,  occurring  as  a  sequel  to  the 
acute  forms  or  beginning  as  a  chronic  affection.  This,  if  prolonged,  may 
lead  to  changes  in  the  joint,  such  as  laxity  of  ligaments,  etc. 

The  effusion,  if  serous,  is  generally  thick  and  may  contain  clots  of 
fibrin.  It  may  be  sero-purulent  or  purulent.  The  effusion  may  be 
colored  by  blood. 

In  the  severer  cases  the  joint  changes  may  not  differ  from  those  de- 
scribed in  the  arthritis  due  to  pysemic  processes.  The  striking  feature, 
insisted  on  by  Finger,  Ghon  and  Schlagenhauf er,  Meyer,  and  Councilman, 
is  the  amount  of  granulation  tissue  formed.  Such  a  process  shows  little 
tendency  to  involve  bone  or  cartilage,  being  essentially  synovial. 

Ankylosis  is  of  course  to  be  feared.  The  inflammation  shows  the 
same  tendency  toward  fibrous  hyperplasia  in  the  joints  that  it  does  in 
the  urethra,  which,  of  course,  tends  to  impair  joint  motion.  In  Miih- 
sam's  41  cases  there  were  7  of  ankylosis.  In  10  cases  of  Manley's  none 
recovered  with  full  motion,  and  half  were  followed  by  ankylosis.  In 
Northrup's  series  the  result  was  recorded  as  follows:  Good,  79;  fair,  69; 
poor,  32 ;  no  record,  72. 

The  affection  has  been  demonstrated  to  be  due  to  the  gonococcus. 
The  gonococci  are  found  in  the  joint  effusion  in  many  cases.  They  are 
more  likely  to  be  found  in  acute  than  in  chronic  cases.  The  gonococci 
may  be  present  in  the  pus  cells  of  the  granulation  tissue,  or  if  in  the  exu- 
date, in  phagocytes  or  in  epithelial  cells  free  or  in  clumps.     They  may, 

'Trans.  Assn.  Am.  Physicians,  vol.  x.,  p.  150. 


CHKONIG   JOINT    DISEASE. 


197 


however,  not  be  found  in  the  effusion  or  in  sections  of  the  synovial 
membrane.  A  mixed  infection  with  pyogenic  organisms  may  be  found, 
or,  rarely,  pyogenic  organisms  alone  may  be  found  in  the  joint  fluid. 
Suppuration  of  the  joint  is  not  necessarily  associated  with  mixed  in- 
fection. 

Men  are  much  more  frequently  affected  than  women.  The  compli- 
cation rarely,  if  ever,  occurs  before  the  third  week  of  the  disease.  It 
occurs  in  about  two  per  cent  of  all  cases,  according  to  the  statistics  of 
Jullien,  Grisolle,  and  Bernier.  Involvement  of  the  joints  may  occur 
after  the  passage  of  a  sound  into  the  urethra,  in  the  vulvo-vaginitis  of 
little  girls,'  and  in  the  gonorrhoeal  ophthalmia  of  babies. 

The  joints  affected  were  as  follows  in  the  order  of  their  frequency  in 
Northrup's  series:  Knee,  91;  ankle,  57;  small  joints  of  foot,  40;  wrist, 
27;  heel  and  toes,  21;  elbow,  18;  hip,  16;  shoulder,  16;  small  joints  of 
hand,  11;  sterno-clavicular  joint,  3;  temporo-m axillary  joint,  2. 

The  prognosis  can  hardly  be  formulated.  The  affection  is  always 
serious  and  generally  slow  in  progress  and  resistant  to  medication.  In 
the  acute  stages  suppuration  is  to  be  feared,  and  impairment  of  motion, 
perhaps  ankylosis,  is  not  unlikely  to  result.  Simple  cases  perhaps  often- 
est  recover  after  a  long  time  with  practically  normal  motion. 

The  duration  in  Northrup's  cases  was: 

<  )ne  to  six  weeks ""* 

8ix  weeks  to  two  months °* 

Two  months  or  more ' ' 

Indefinite ° ' 

The  various  treatments  advised  for  this  affection  are  hardly  worth 
while  enumerating.  In  acute  synovitis  the  affection  should  be  treated 
like  other  forms  of  synovitis  and  the  fluid  withdrawn  from  time  to  time 
for  examination.  Suppuration  demands  incision  and  drainage.  Convales- 
cent cases  should  be  treated  as  if  convalescent  from  ordinary  synovitis, 
only  Avith  greater  care. 

Obstinate  and  persistent  chronic  synovitis,  if  in  the  hip,  should  be 
treated  by  protection,  and  perhaps  traction  by  apparatus.  More  accessi- 
ble joints  are  best  treated  by  free  incision  and  flushing  out  with  hot 
'  sterile  water  or  hot  weak  corrosive  solution  in  obstinate  cases.  Drainage 
for  a  few  days  should  be  kept  up  by  strips  of  gauze,  and  the  joint  should 
be  washed  out  daily  in  severe  cases.  The  experience  of  the  writers  has 
been  that  in  such  cases  incision  and  drainage  have  been  followed  by  cessa- 
tion of  pain  and  speedy  restoration  of  motion. 

The  experience  of  the  writers  has  not  been  favorable  to  the  rubbing  in 
of  ointments  (iodoform,  etc.)  or  to  the  use  of  the  many  external  applica- 

>  Beclerc  •  Tlevue  mens,  des  Mai.  de  l'Enfance,  1802,  p.  278. 


19S  ORTHOPEDIC    SURGERY. 

tions  advised.  If  operation  is  not  practicable  the  ordinary  measures  in 
use  for  the  treatment  of  chronic  synovitis  are  to  be  used. ' 

VII.   Pathological  Conditions  of  the  Nervous  System. 

A  destructive  form  of  joint  disease  may  be  associated  with  locomotor 
ataxia,  syringomyelia,'-  Pott's  disease,  acute  myelitis,3  injuries  of  the 
peripheral  nerves,  cerebral  apoplexy,  tumors  of  the  cord,,  crushing  of 
the  spinal  cord,4  and  progressive  muscular  atrophy.  A  form  of  joint  dis- 
ease is  described  by  Laborde5  as  occurring  in  anterior  poliomyelitis. 

These  affections  are  called  Charcot's  joint  disease,  spinal  or  neuro- 
pathic arthropathy,  neural  arthropathy,  tabetic  arthropathy,  etc. 

The  pathological  process  is  in  many  respects  similar  to  that  in  arthri- 
tis deformans  except  that  the  destructive  process  is  more  rapid  and  the 
formative  activity  less.  The  cartilage  disintegrates,  the  ends  of  the 
bones  are  exposed  and  may  be  rapidly  Avorn  away,  the  synovial  mem- 
brane and  ligaments  thicken  and  ulcerate.  This  process  niay  result  in 
spontaneous  luxation  in  severe  cases.  Synovial  effusion  may  be  present, 
and  suppuration  may  occur.  Hypertrophy  of  the  epiphyses  may  take 
place  as  well  as  the  formation  of  osteophytes,  but  atrophic  changes  pre- 
dominate. The  essential  character  of  the  affection  is  the  rapid  melting 
away  of  cartilage  and  bones. 

The  affection  is  most  often  monarticular,  and  although  adults  are 
generally  affected,  cases  have  been  recorded  as  early  as  the  sixth  year. 
The  joints  are  affected  in  approximately  the  following  order  of  frequency : 
In  107  individuals  the  knee  was  affected  78  times,  the  hip  31  times,  the 
shoulder  21  times,  the  tarsus  13  times,  the  elbow  10  times,  the  ankle  9 
times,  the  wrist  twice,  the  jaw  twice,  and  the  spine  once. 

1  Finger:  "Blennorrhea,"  1893,  p.  327;  Rindfleisch :  Langenbeck's  Archiv, 
vol.  lv.,  S.  445;  Finger,  Glion,  and  Schlagenhaufer  :  Arch.  Derm.  u.  Syph.,  xxviii., 
1894;  ibid.,  1895;  Mtihsam :  Mitth.  a.  d.  Grenzgebieten  der  Med.  u.  d.  Chir.,  ii.,  Hit. 
5;  Meyer:  Centralbl.  f.  Chir.,  1898,  No.  1,  p.  20;  Therese :  Gaz.  des  Hop.,  1894, 
lxvii.,38;  Osier:  "Pract.  Med.,"  1896;  Hartley:  N.  Y.  Med.  Jour.,  1887,  377;  Gui- 
teras:  N.  Y.  Med.  Jour.,  1894,  lix.,  355;  Parizeau  :  Gaz.  hebd.  de  M6d.  et  de  Chir., 

1890,  953;  Neisser :  Deutsche  med.  Wochenschr.,  1894,  No.  15;  Eespighi  et  Burci  : 
Ann.  de  Derm,  et  Syph.,  1895,  270;  Eespighi :  Bull,  de  Soc.  Med.  Pisana,  1895,  No. 
2  (ref.  Baumgarten);  Rubinstein:  Therap.  Monatsheft,  1890,  iv.,  379;  Bordoni 
Ufreduzzi  :  Deutsche  med.  Woch.,  1894,  484;   Brodhurst :  Trans.  Am.  Orth.  Assn., 

1891,  iv.,  59;  Tyson:  Univ.  Med.  Mag.,  1889-90,  ii.,  625;  Bond:  Westminster 
Hosp.  Rep.,  1889,  v.,  163;  Widal :  Soc.  Med.  des  H6p.  de  Paris,  1895,  607;  Man- 
ley:  Am.  Jour.  Med.  Sciences,  1894;  B^clerc  :  Rev.  Mens,  des  Mai.  de  l'Enfance, 

1892,  p.  278. 

2Rokoloff :  Deutsch.  Zeit.  f.  Chir.,  1892,  xxxiv.,  505. 
3 Mitchell:  Am.  Jour.  Med.  Sciences,  April,  1875. 

4Riedel :  Berl.  klin.  Woch.,  1883,  xvii.  ;  Joffroy :  Gaz.  rn£d.  de  Paris,  1872,  vi. 
and  viii. 

•'Laborde:  Bull,  de  la  Soc.  d'Anat.,  1873,  p.  744. 


CHRONIC   .JOINT   DISEASE. 


199 


So  far  it  cannot  he  said  that  the  lesion  of  any  one  set  of  nerve  struc- 
tures is  the  definite  cause  of  the  joint  disturbance.' 

The  joint  changes  may  he  present  at  an  early  stage  of  the  nervous 
disorder. 

Swelling,  effusion,  disability,  and  sometimes  pain  are  the  first  signs  of 
the  joint  involvement.  Spontaneous  arrest  of  the  process  may  occur,  an- 
kylosis may  rarely  result,  or  more  commonly  the  joint  is  disorganized  to 
the  point  of  luxation.  The  diagnosis  is  often  difficult,  especially  in  the 
early  stages.     The  resemblance  to  malignant  disease  is  at  times  striking,  as 


Fig.  181.— Charcot's  Disease  of  Elbow.    Opening  made  to  obtain  specimen  lor  microscopical  ex- 
amination. 

in  a  case  of  one  of  the  writers  shown  in  Fig.  181.  The  removal  of  a  bit 
of  the  tissue  will  of  course  serve  to  establish  the  character  of  the  process 
present. 

The  treatment  does  not  differ  essentially  from  that  of  inflamed  joints 
in  general.  The  nervous  lesion  must  be  treated,  and  although  excision2 
has  been  successfully  done  under  these  conditions,  local  operative  meas- 
ures are  not,  as  a  rule,  to  be  advised. 


VIII.  H-emophilia,    Scurvy,   etc. 

Hcemophilia  is  accompanied  at  times  by  characteristic  joint  lesions 
which  in  their  clinical  resemblance  to  tuberculosis  are  worthy  of  notice. 
Like  other  manifestations  of  this  diathesis  they  occur  in  male  children  or 
young  adults,  decreasing  in  frequency  with  increasing  age  (Gocht).  The 
hemorrhage  may  be  intra-articular  or  peri-articular.  After  repeated  acute 
attacks  of  hemorrhage  into  the  joint  chronic  joint  changes  are  likely  to  en- 

1  Cf.  Charcot,  vol.  L,  p.  121.      2  Wolff :  Deutscli.  med.  Zeit.,  March  15th,  1888. 


200  ORTHOPEDIC    SURGERY. 

sue.  There  is  an  overgrowth  of  brown-stained  synovial  tufts.  The  cartil- 
age may  degenerate,  and  sharp  bordered  defects  in  it  are  frequently  found. 
Adhesions,  contractions  of  the  capsule,  and  bony  displacements  may  occur. 

Erosion,  of  the  ends  of  the  bones  may  take  place  along  with  a  prolife- 
ration at  the  edges  not  nnlike  rheumatoid  arthritis.  A  brown  staining 
of  all  the  joint  structures,  except  the  cartilage,  is  described  as  character- 
istic. Rheumatic  pains  are  a  common  clinical  accompaniment  of  the 
affection.  The  character  is  essentially  chronic.  Swelling  and  muscular 
spasm  are  present  during  attacks  of  irritation,  and  the  diagnosis  from 
tuberculosis  is  to  be  made  more  from  the  history  than  from  any  char- 
acteristic features.1 

Konig  reports  two  fatal  hemorrhages  occurring  as  the  result  of  opera- 
tion on  these  supposedly  tuberculous  joints. 

Protection  to  the  diseased  joints  is  of  more  use  than  any  other  one 
measure,  but  the  prognosis  as  to  recovery  is  doubtful  at  best.  Aspiration 
with  a  small  needle  may  be  safely  done  for  purposes  of  diagnosis. 

Spontaneous  bleeding  into  joints  in  persons  not  bleeders  has  been 
recorded  (Isambert2). 

Scurvy.- — Joint  affections  in  infantile  scurvy  are  not  uncommon. 
They  simulate  closely  epiphysitis.  The  enlargement  may  be  confined  to 
one  of  the  bones  forming  an  articulation.  The  thickening  is  due  to  peri- 
articular or  rather  subperiosteal  hemorrhage.  The  joint  itself  is  not  usu- 
ally unaffected,  though  hemorrhage  may  occur.  Such  joints  yield  readily 
to  the  usual  treatment  of  infantile  scurvy.  Such  apparent  inflammation 
of  joints  occurring  in  scurvy  is  regarded  as  being  more  often  due  to  extra- 
articular than  to  intra-articular  lesions,  subperiosteal  hemorrhage  being 
the  most  frequent  lesion.  In  379  cases  of  scurvy  investigated  by  the 
American  Pediatric  Society3  there  were  swellings  in,  or  more  often  about, 
the  joints  in  165.  These  were  distributed  as  follows:  Knee  73,  ankle 
28,  wrist  12,  hip  6,  shoulder  5,  elbow  3,  hand  1. 

In  40  analyzed  with  regard  to  the  coexistence  of  rickets,  in  45  per  cent 
there  were  symptoms  of  rickets,  while  in  55  per  cent  rickets  was  said  to 
be  definitely  absent. 

Pulmonary  Hypertrophic  Osteo-arthropathy. — This  the  name  given  to 
a  condition  occurring  sometimes  in  connection  with  chronic  pulmonary 
disease  in  which  the  fingers  are  clubbed  and  stiffened,  the  shafts  of  the 

■Linser:  Brans'  Beitr.  zur  klin.  Ch.,  Bd.  xvii.,  105 ;  Shaw:  Bristol  Med.- 
Chiv.  Journal,  1897,  xv.,  240;  Konig:  Volkmann's  Saniml.  klin.  Arortrage  (Transl. 
Med.  Surg.  Reporter,  lxvi.,  No.  20,  p.  999) ;  Legg:  St.  Barth.  Hosp.  Rep,,  xvii.,  1881, 
303;  Pearce:  Brit.  Med.  Jour.,  1898,  i.,  1135;  Summers:  Med.  Rec,  1890,  xlix., 
330;  Liibke :  Deutsch.  Zeit.  f.  Chir.,  xlix.,  014;  Goelit :  Munch,  med.  Wochensclir., 
1899,  February  21st,  271. 

2  For  normal  processes  of  absorption  of  blood  in  joints  see  Jaffe  :  Langenbeck's 
Archiv,  Bd.  liv.,  Hft.  1. 

3  Boston  Med.  and  Surg.  Jour.,  vol.  cxxxviii.,  007. 


CHRONIC    JOINT   DISEASE.  201 

bones  are  thickened,  and  the  spine  is  bent  forward  in  a  kyphosis.     The 
relation  of  the  affection  to  acromegaly  and  osteomalacia  is  not  clear. 

In  this  condition  the  joints  are  occasionally  swollen  and  painful  with 
effusion.  The  changes  as  shown  by  autopsy1  are  synovitis  and  thinning 
of  the  articular  cartilages  even  to  the  extent  of  exposing  the  bone. 
Along  with  this  is  associated  periostitis  and  some  sclerosis  of  bone  which 
may  involve  the  shaft. 

IV.  Miscellaneous  Conditions. 

Lipoma  may  occur  in  the  joint  beneath  the  synovial  membrane,  often 
causing  chronic  synovitis.  The  mass  may  vary  from  the  size  of  an  al- 
mond to  that  of  a  small  egg.  These  growths  may  apparently  be  true  lipo- 
mata2  springing  from  the  fat  pads  beside  the  patella,  or  they  may  be  as- 
sociated with  tuberculosis  or  arthritis  deformans.  The  form  of  lipoma 
not  unusual  with  arthritis  deformans  is  that  showing  great  numbers  of 
relatively  small  fatty  villi,  the  lipoma  arborescens  so  called. 

Loose  bodies  in  the  joints  are  found  most  often  in  the  knee,  but  occa- 
sionally in  other  articulations.  The  other  names  for  the  condition  are, 
loose  cartilages,  joint  mice,  floating  or  movable  bodies  in  joints,  mures 
articulorum,  corpora  libera  articnlorum,  etc.  They  can  be  divided  into 
classes,  according  to  their  structure,  as  follows :  fibromatous,  lipomatous, 
chondromatous. 

They  are  formed  in  one  of  the  following  ways : 

(a)  As  the  fibrinous  residue  of  an  exudation. 

(b)  As  the  residue  of  a  blood  clot,  a  theory  which  rests  rather  on  the 
consensus  of  opinion  than  on  accurate  demonstration. 

(c)  As  broken-off  osteophytes  in  arthritis  deformans. 

(d)  As  hypertrophied  or  degenerated  synovial  tufts. 

(e)  As  marginal  ecchondroses  broken  off,  as  in  arthritis  deformans. 
(/)  As  encapsulated  foreign  bodies,  such  as  bullets  and  needles. 

(g)  As  bits  of  cartilage  or  bone  chipped  off  by  traumatism  or  loosened 
by  a  degenerative  process  the  result  of  traumatism.3  The  fact  that  a  fall 
may  be  the  cause  of  this  variety  of  loose  body  has  been  clearly  proved. 

Formerly  it  was  held  that  free  bodies  (of  the  chondromatous  class) 
were  the  result  of  the  direct  forcible  tearing  off  of  pieces  of  cartilage 
by  wrenches  or  strains  or  blows.  The  more  modern  view  is  represented 
by  Konig,  who  does  not  deny  the  possibility  of  this  tearing  off  of  bits 

•Lefebre:  These  de  Paris,  1891;  Ranzier:  Rev.  de  Med.,  1891,  p.  30;  Trans. 
Path.  Soc,  1896,  xlvii.,  177;  Whitman,  Pediatrics,  1899,  vii.,  Nos.  4  and  5  (with 
bibliography). 

-Stieda:  Beitr.  z.  klin.  Chir.,  1896,  xvi.,  285. 

JSt.  George's  Hosp.  Rep.,  1867,  ii.,  141;  Volkmann  :  Deutsch.  Klinik,  1867, 
No.  48. 


202  ORTHOPEDIC   SURGERY. 

of  cartilage,  but  he  insists  upon  its  rarity  and  shows  the  great  force 
necessary  to  detach  them  in  this  way.  Rather,  it  should  be  considered 
that  these  pieces  are  so  bruised  and  injured  by  the  trauma  that  their 
necrosis  follows,  and  that  a  spontaneous  osteochondritis  then  takes  place 
which  leads  to  their  detachment  and  sets  them  free  In  the  joint.  Cases 
in  which  the  traumatic  origin  of  these  chondromatous  free  bodies  is  be- 
yond question  are  given ;  notably  one '  in  which,  three  weeks  after  a 
wrench  to  the  knee,  a  free  body  was  removed  by  Mr.  Simon,  which  Mr. 
Shattock  pronounced  to  be  a  piece  of  the  articular  surface. " 

There  seems  reason  to  believe  that  in  spite  of  the  lack  of  blood-ves- 
sels these  bodies  are  nourished,  after  being  set  free  in  the  joint;  not  only 
does  ossification  of  them  take  place  after  they  are  freed,  but  the  case  of 
Recklinghausen  would  seem  to  show  that  growth  is  also  possible. 

Loose  bodies  lie  free  in  the  joint  or  are  attached  by  a  slender  pedicle. 
They  may  vary  in  size  from  that  of  a  small  pea  to  that  of  a  horse  chest- 
nut, and  are  of  all  shapes.  The  smaller  ones  are  most  often  shaped  like 
melon-seeds,  or  are  irregularly  round,  while  the  larger  ones  are  more  regu- 
larly round,  concavo-convex,  or  spherical.  Sometimes  they  are  facetted 
and  crowded  together  like  the  carpal  bones,  and  again  they  are  mul- 
berry-shaped or  pyriform.  In  one  joint  they  may  appear  singly  or  in 
great  numbers,  and  they  may  vary  a  great  deal  in  size  in  the  same  joint. 
Over  four  hundred  have  been  removed  from  one  knee-joint. ;f  Next  in 
frequency  to  the  knee  comes  the  elboAv,4  and  all  of  the  larger  joints  are 
liable  to  contain  these  bodies.  In  external  appearance  they  are  whitish 
or  yellowish,  and  vary  from  a  soft  consistency  to  a  bony  hardness.  On 
section  they  show  either  a  plain  fibrous  structure,  or  a  fibrous  sheath 
enclosing  a  mass  of  fat.  Again,  the  structure  is  of  hyaline  or  fibro-carti- 
lage,  ordinarily  without  corpuscles,  or  of  bone  tissue,  most  often  without 
Haversian  canals.  Frequently  they  present  a  combination  of  two  of 
these  forms. 

They  are  often  found  in  connection  with  the  changes  known  as  arthri- 
tis deformans,  and  also  in  joint  disease  of  various  types.  They  may  be 
found  in  connection  with  joint  tuberculosis.  In  certain  cases  no  cause 
can  be  assigned  for  their  occurrence. 

Joint  Disease  Secondary  to  Peri- articular  Abscess. — Suppuration  in  the 
periarticular  cellular  tissue  and  subsequent  affection  of  the  joint  may 
start  from  an  open  skin  wound  which  has  been  infected,  or  from  an  in- 

»  Marsh:  Brit.  Med.  Jour.,  April  14th,  1888. 

2  Shattock  :  Path.  Trans.,  xv.,  p.  206. 

3  Howard  Marsh  :  "Diseases  of  Joints,"  p.  18o  ;  Harwell :  "Diseases  of  Joints." 
p.  268,  London,  1881. 

4Kdnig:  Arch.  f.  klin.  Chir.,  1888;  cf.  Brodhurst:  St.  George's  Hospital 
Reports,  1867.  ii.  s..  141-144,  and  Volkmann  :  Deutsche  Klinik,  1867,  No.  48  ;  "Die 
krankhaften  Geschwiilste,"  p.  4.r>0.  Berlin,  1-863. 


CHRONIC   JOINT   DISEASE.  203 

jury  to  the  limb  in  which  cellulitis  has  come  on  in  consequence  of  the 
trauma.  Again,  in  children  of  feeble  type,  periarticular  abscess  of  a 
slow  and  chronic  character  may  arise  after  slight  bruises,  and  sometimes 
after  no  perceptible  injury  at  all.  Any  of  these  abscesses,  if  they  are 
not  at  once  evacuated,  are,  of  course,  likely  to  infect  a  neighboring 
joint;  occasionally,  the  abscess  from  one  diseased  joint  burrows  a  long 
distance,  and  in  its  course  either  opens  into  another  joint  or  passes  so 
near  to  it  that  infection  of  the  second  joint  takes  place. 

Growing  Pains. — A  joint  affection  incident  to  growth  has  been  de- 
scribed by  Bouilly,  and  has  long  been  known  but  unclassified  by  practi- 
tioners, and  popularly  considered  to  be  incident  to  growth — "growing 
pains."  There  is  slight  pain  chiefly  in  the  juxta-epiphyseal  region, 
most  commonly  near  the  lower  epiphysis  of  the  femur.  This  pain  is 
brought  on  by  fatigue,  strains,  or  exposure.  In  the  lightest  cases  the 
symptoms  pass  away  in  a  few  hours.  In  severer  forms  they  may  last 
for  several  days,  and  the  pain  may  be  accompanied  by  slight  fever.  In 
the  severest  form  the  affection  may  continue  for  months.  There  may  be 
slight  effusion  in  the  joints,  but  recovery  eventually  takes  place.  It 
may  occur  during  the  ages  between  five  and  twenty-one. ' 

A  great  amount  of  harm  is  done  in  referring  to  this  class  the  pains  of 
beginning  chronic  joint  disease.  Growing  pains  proper  are  neither  severe 
nor  permanent. 

Analogous  to  this  may  be  mentioned  what  has  been  termed  by  French 
writers  maladie  de  la  croissance — which  is  in  reality  a  hypersemia  and 
sensitiveness  of  the  epiphysis  in  adolescents — analogous  to  what  is  seen 
occasionally  in  rickets. 

Ankylosis  is  the  name  applied  to  the  stiffened  condition  of  a  joint.  It 
is  often  subdivided  into  two  classes,  true  ankylosis  when  the  union  is 
bony,  and  false  ankylosis  when  it  is  fibrous.  But  this  subdivision  is  not 
universally  accepted.  Ankylosis  is  most  often  the  result  of  joint  inflam- 
mation, the  products  of  which  inflammation  are  transformed  into  fibrous 
tissue.  If  the  inflammation  has  been  severe  enough  to  expose  the  ends  of 
the  bones  they  may  be  united  by  a  connecting  formation  of  bone.  The 
same  joint  may  in  part  be  obliterated  by  connecting  bone  while  in  other 
parts  of  the  same  joint  fibrous  connecting  bands  exist.  The  character  of 
the  ankylosis,  whether  fibrous  or  bony,  depends  in  large  measure  upon 
the  character  and  extent  of  the  inflammation  causing  it.  The  limitation 
or  prevention  of  ankylosis  in  joint  disease  obviously  depends  upon  the 
efficient  treatment  of  joint  inflammation. 

The  fixation  of  healthy  joints  for  a  reasonable  time  cannot  be  considered 
as  likely  to  produce  ankylosis.  A  degenerative  rather  than  an  inflamma- 
tory process  was  found  in  healthy  joints  immobilized  by  Reyher  for  a  year. 

1  Gaz.  des  Hop.,  1883,  p.  1034. 


204  ORTHOPEDIC   SURGERY. 

Among  joint  inflammations  causing  ankylosis  by  virtue  of  their  proc- 
ess of  repair  may  be  mentioned  especially  synovitis,  particularly  of  the 
purulent  form,  and  tuberculosis  of  joints. 

Intra-articular  fractures,  especially  with  displacement  of  bone,  must 
be  accoiinted  as  a  frequent  cause  of  ankylosis. 

Cicatricial  contraction  of  the  joint  capsule  as  well  as  connecting 
fibrous  bands  may  cause  the  loss  of  motion  in  a  joint. 

The  name  ankylosis  should  not  be  applied  to  the  stiffness  of  joints 
due  to  the  tonic  muscular  spasm  of  acute  or  chronic  joint  disease. 

In  bony  ankylosis  it  is  evident  that  nothing  but  a  cutting  operation 
can  be  of  use.  If  such  joints  are  fixed  at  improper  angles,  excision  or 
osteotomy  of  the  joint  may  be  performed,  followed  by  a  replacing  of  the 
joint  at  a  proper  angle  when  ankylosis  will  again  occur,  but  in  a  different 
position.  An  elbow  ankylosed  in  a  straight  position  is  a  disabling  de- 
formity, but  the  same  arm  is  of  much  use  when  the  elbow  is  fixed  at  a 
right  angle. 

The  success  of  other  treatment,  such  as  manipulation  and  stretching, 
in  the  fibrous  form  of  ankylosis  will  depend  on  the  character  and  resist- 
ance of  the  fibrous  bands  constituting  the  ankylosis.  The  patient  may 
be  etherized  and  manipulation  be  attempted.  If  the  ankylosis  is  bony 
nothing  can  be  accomplished.  If  the  fibrous  bands  are  very  resistant 
motion  cannot  be  obtained  and  the  use  of  extreme  force  will  do  more 
harm  than  good  in  starting  up  fresh  inflammation.  If  the  fibrous  bands 
are  few  and  small  they  may  be  stretched  or  ruptured  by  the  use  of  mode- 
rate force,  and  if  the  following  joint  inflammation  is  not  severe  much 
may  have  been  gained.  Such  forcible  manipulations  must  be  followed 
by  passive  motion  at  frequent  intervals.  Gentle  manipulation  from  the 
first  in  connection  with  massage  is  preferable  to  the  use  of  force  in  suit- 
able cases.  The  question  of  ankylosis  has  been  discussed  under  the 
various  joints.  Massage,  hot-air  baths,  and  the  use  of  elastic  and 
mechanical  force  are  all  of  use  in  connection  with  manipulation. 

Bursitis. — The  inflammation  of  bursas  may  easily  lead  to  an  affection 
of  the  joints.  The  more  frequent  of  these  forms  of  bursitis  will  be  de- 
scribed in  speaking  of  the  individual  joints. 

As  other  causes  of  impairment,  rather  than  disease,  of  joints,  may  be 
mentioned  the  following :  cicatrices  after  burns,  wasting  of  muscles  and 
ligaments  after  infantile  paralysis,  and  muscular  contractions  causing 
malpositions  of  the  joints  after  hemiplegia,  fractures  involving  the  joints, 
etc. 


CHAPTER  Y. 

HIP   DISEASE. 

Definition. —  Pathology.— Clinical    history.— Diagnosis.— Differential    diagnosis.— 
Prognosis. — Treatment  (mechanical — operative). 

The  affection  which  is  commonly  known  as  hip  disease  is  the  most 
frequent  affection  of  the  hip-joint,  and  by  common  usage  the  general 
name  of  "  hip  disease  "  or  "  hip-joint  disease  "  has  become  limited  to  that 
especir.l  affection  of  the  joint  which  comes  now  for  consideration.  It  is 
known  also  by  the  names  of  morbus  coxarius  or  morbus  coxse,  coxalgia, 
coxitis,  chronic  articular  ostitis  of  the  hip,  and  coxo-tuberculose  (Lanne- 
longue).  The  pathological  condition  commonly  found  is  a  chronic 
tuberculous  ostitis  of  the  epiphysis  of  the  head  of  the  femur  or  of  the 
acetabulum. 

Pathology. 

The  pathology  of  hip  disease  has  already  been  considered  in  its  gen- 
eral aspect  along  with  the  other  forms  of  tuberculous  joint  disease  in  the 
previous  chapter. 

Although  probably  in  most  cases1  the  head  of  the  femur  is  the  pri- 
mary seat  of  disease,2  in  others  the  acetabulum  is  the  part  first  affected.3 
In  Wright's  100  cases  the  acetabulum  was  necrosed  or  perforated  in  27, 
in  14  of  which  there  seemed  reason  to  believe  that  the  femur  was  first 
affected.  In  49  other  cases,  however,  the  acetabulum  was  superficially 
diseased. 

When  once  the  acetabulum  has  become  diseased  either  primarily  or 
secondarily,  enlargement  of  it  is  apt  to  take  place.  The  irritated  pelvic 
femoral  muscles  which  are  in  a  state  of  tonic  contraction  crowd  the  head 
of  the  femur  against  the  upper  and  back  border  of  the  acetabulum;  under 
this  continual  pressure  absorption  of  that  portion  of  the  rim  of  the 
acetabular  cavity  takes  place  with  an  actual  enlargement  of  the  cavity 
from  below  upward.     This  so-called  migration  of  the  acetabulum  is  one 

'Konig:  Deutsch.  Zeit.  f.  Chir.,  xi.,  1879. 

5  Konig  :  "  Die  Tuberc.  der  Knochen  und  Gelenke,"  Berlin,  1884  ;  G.  A.  Wright : 
"Hip  Dis.  in  Childhood,"  p.  17. 

3Habern:  Cent.  f.  Chir.,  April  2d,  1881;  E.  H.  Nichols:  Orth.  Trans.,  vol.  xi., 
p.  353. 


206 


ORTHOPEDIC    SURGERY. 


cause  of  shortening  of  the  limb,  and  measurement  will  show  that  the 
trochanter  lies  above  Nekton's  line. 

The  changes  in  the  head  of  the  femur  are  chiefly  the  result  of  ostitis 
and  pressure.     There  may  be  alteration  in  the  shape  of  the  head  of  the 


Fig.  182.— Erosion  of  the  Upper  Part  of  the  Acetabulum.    (New  York  Medical  Journal.) 

bone,  if  it  is  worn  away  by  the  pressure  induced  by  constant  muscular 
spasm  and  destruction  of  the  articular  surface.  The  appearance  of  the 
cartilage,  as  described  under  the  pathology  of  that  structure,  often  sug- 
gests ulceration,  and  hence  arose  the  theory  that  the  original  seat  of  hip 
disease  was  to  be  found  in  the  cartilage. 


HIP   DISEASE. 


2  or 


"  Dislocation  "  of  the  hip  in  hip  disease  is  a  term  often  used  which  is 
perhaps  misleading.  True  dislocation  in  ordinary  tuberculous  ostitis  of 
the  hip  rarely  occurs,  but  partial  destruction  of  the  softened  head  of  the 


Fig.  183.— Pathologically  Enlarged  Acetabulum. 


Fig.  184.— Acetabular  Coxitis. 


femur  in  the  manner  just  described  may  lead  to  a  shortening  of  the  limb 
and  to  an  elevation  of  the  trochanter  above  its  proper  level.  The  wear- 
ing away  of  the  acetabulum  produces  the  same  result ;  but  true  disloca- 


Fig.  185. — Erosion  of  the  Head  of  the  Femur. 


Fig.  186.— Erosion  of  the  Head  of  the  Femur. 


tion  is  rare,  because,  even  if  the  head  of  the  bone  is  almost  entirely 
destroyed,  there  is  so  much  inflammatory  tissue  deposited  about  the  joint 
that  the  head  of  the  bone  is  retained  partly  in  place. 

Fracture  of  the  atrophied  and  degenerated  shaft  of  the  femur  may 
occur  in  occasional  cases.  Separation  of  the  head  of  the  femur  at  the 
epiphyseal  line  is  less  uncommon  (Fig.  188). 


208 


ORTHOPEDIC    SURGERY. 


A  typical  specimen  from  a  fairly  advanced  case  of  hip  disease  shows 
a  reddened  and  thickened  synovial  membrane,  perhaps  even  broken  down 
into  granulations ;  the  cartilage  is  gone  from  the  head  of  the  femur  or 


Fig.  18?.— Focus  in  Head  of  Femur. 


hangs  in  tags  or  shreds,  and  the  general  appearance  of  the  end  is  often 
spoken  of  as  "  worm-eaten  "  ;  sometimes  the  whole  cartilage  may  be  lifted 


Fig.  188.— Separation  of  the  Head  of  the  Femur  at  the  Epiphyseal  Line. 


from  the  bone  by  a  layer  of  granulations.     The  epiphyseal  portion  of  the 
head  of  the  femur  has  disappeared  in  part  or  altogether,  and  a  ragged, 


I1II'    DISEASE. 


I'd!) 


carious  end  of  bon^  will  articulate  with  an  acetabulum  covered  with  fun- 
gous granulation  in  part  or  wholly  replacing  cartilage. 

The  whole  epiphysis  may  form  one  sequestrum,  but  this   is  not  com- 
mon.     Sometimes    it 

lies  in  the  epiphysis,  .  JSTSfy 

but  more  commonly  it    "-- ___  tM        [  '&  ■   .^ 


/ 


h 


FIG.  189.— Head  and  Neck  of  Femur 
from  Excised  Hip.  Head  denuded  of 
cartilage.  No  primary  focus  found. 
ft,  Head  denuded  of  cartilage  ;  b,  neck. 
(Nicnois.1 


Fig.  190.— Hip  Disease.  I'roeess  extended  from  primary 
focus  in  acetabulum  along  round  ligament,  a,  Head  of 
femur  covered  with  elevated  cartilage  ;  b,  neck.    (Nichols. 


extends  on  both  sides  of  the  epiphy- 
seal line;  while  sometimes  the  dead 
bone  extends  some  little  distance  into 
the  diaphysis. 

Perforation  of  the  floor  of  the  ace- 
tabulum may  take  place.  Inside  of 
the  pelvis  a  dense  wall  of  fibrous  tis- 


Fig.  191. -Hip.  Excised  head  of  femur.  Ar- 
ticular cartilage  turned  up  at  one  side  shows 
tuberculous  bone  beneath.  Primary  focus  was 
in  acetabulum,  «,  Head  of  femur,  surface  tuber- 
cles; b.  elevated  eartilasre.    (Nichols.) 

14 


Fu,.  19:2.— Acetabulum  Seen  from  Outside,  a.  Tu- 
berculous granulations;  b,  tuberculous  cavity. 
(Nichols.) 


2 1 0 


ORTHOPEDIC   SURGERY. 


sue  and  thickened  periosteum  shuts  off  the  head  of  the  femur  or  the 
contents  of  the  joint  from  the  pelvic  cavity.  In  cases  in  which  the 
disease  has  gone  on  as  far  as  this,  disease  of  the  pelvic  bones  may  co- 
exist.    In  the  other  direction,  when  once  the  disease  of  the  femur  has 

passed  the  epiphyseal 
line,  there  is  no  limit 
to  be  set  to  its  course 
or  its  extent  of  destruc- 
tion. 

Abscesses  appear  ex- 
ternally if  the  disease  of 
the  joints  extends  to  the 
periarticular  tissues,  or 
when  a  separate  focus  of 
disease  forms  outside  of 
the  joint  and  spreads  to 
the  surrounding  soft 
parts.  Suppuration  inside 
of  the  pelvis  is  not  a  very 
uncommon  condition  in 
the  acetabular  form  of  the 
disease;  in  the  femoral 
form  it  accompanies  only 
advanced  disease.  It 
arises  most  commonly 
from  perforation  of  the 
acetabulum  or  from  in- 
flammation inside  the  pel- 
vis excited  by  the  bone 
disease  in  the  neighbor- 
hood; or,  again,  the  pus 
may  ascend  to  the  brim 
of  the  pelvis,  either  in 
the  sheath  of  the  psoas 
muscle  or  in  other  tissues,  and  then  gravitate  down  the  inner  wall. ' 

A  natural  cure  results  in  one  of  two  ways :  by  the  absorption  or  calci- 
fication of  the  tuberculous  tissue  at  an  early  or  a  late  stage  of  the  dis- 
ease ;  or  by  the  purulent  degeneration  of  such  tissue  and  its  evacuation 
and  discharge  by  an  external  opening.  The  suppuration  which  comes 
later  seems  to  be  nature's  effort  to  eliminate  the  diseased  material,  and 
it  is  the  common  method  by  which  spontaneous  cure  results  when  it  does 
occur.     This  late  stage  of  the  disease  is  characterized  by  malpositions 


Fig.  193.— Hip.  Section  through  femur  and  acetabulum. 
Some  erosion  of  acetabulum  upward.  Ankylosis  without  dis- 
location, a,  Ankylosis ;  i>,  head  of  femur ;  c,  acetabulum. 
(Nichols.) 


R.  W.  Parker:  Chir.  Soc.  Trans.,  1880. 


UII'    DISKASK. 


211 


The  articular  surfaces  have 


and  shortening  of  the  limb  and  much  impairment  of  the  general  condition 
in  most  cases.  It  is  this  state  of  affairs  that  makes  the  spontaneous  cure 
of  hip  disease  undesirable  and  imperfect.  When  spontaneous  cure  does 
occur  it  is  usually  with  an  ankylosed  joint, 
been  destroyed  by  the  „--''" 

.  '  i 


•-* 


disease  and,  in  part  of 
the  joint  at  least,  erod- 
ed granulating  bone 
surfaces  are  in  contact. 
These  surfaces  become 
united  by  adhesions,  or 
ossification  of  the 
cicatrizing  tissues  may 
eventually  take  place 
and  all  the  parts  solidi- 
fy into  one  mass. 

In  these  cases, 
however,  one  some- 
times finds  at  autopsy 
an  included  cheesy 
focus  which  still  pre- 
sents some  signs  of 
activity.  It  is  to  these 
foci  that  one  looks  for 
an  explanation "**of  the 
late  relapses  of  the 
disease  and  the  very 
great  harm  which  is 
sometimes  done  by 
forcible  manipulation  of  these  joints  and  consequent  lighting  up  of  the 
original  tuberculous  disease.1 


Fig.  194.— Head  of  Femur  Eroded,  Partly  Destroyed,  Partly  Dislo- 
cated. Fibrous  ankylosis,  a,  Head  of  femur;  b,  eroded  head  of  fe- 
mur; c,  ankylosis;  d,  acetabulum.    (Nichols.) 


CiiisricAii  History. 

Early  Symptoms. — The  beginning  of  the  affection  is  most  often  grad- 
ual and  insidious,  but  at  times  it  begins  so  abruptly,  according  to  the 
parents'  account,  as  to  suggest  a  traumatic  origin.  The  child  will  be 
noticed  to  limp  at  times  with  intervals  of  comparative  freedom  from  lame- 
ness. This  lameness  increases,  and  it  will  be  found  that  the  patient  is 
inclined  to  strike  the  ball  of  the  foot  rather  than  the  heel  in  walking ;  al- 
though the  heel  can  be  put  down  to  the  floor,  yet  instinctively  the  knee 
is  slightly  bent  and  the  heel  raised  when  the  weight  of  the  trunk  falls  on 
the  hip.     There  is  a  certain  amount  of  stiffness  of  gait  apparent  in  the 


1  Trans.  American  Orthopedic  Association,  vol.  i. 


212 


ORTHOPEDIC    SURGERY 


morning  when  the  patient  first  gets  out  of  bed,  and  after  sitting  for  a 
while ;  this  passes  away  after  the  patient  has  walked  or  played  about. 
At  night,  as  a  rule,  the  limp  is  less  than  in  the  morning.  The  limp  can 
perhaps  best  be  described  as  a  very  slight  stiffness  and  a  disinclination 
to  bear  prolonged  weight  upon  the  affected  limb. 

If  the  child  be  inspected  it  will  be  seen  that,  although  able  to  run 
about  and  play  freely,  there  is  a  noticeable  limp,  and  that  in  standing 


Fig.  195.— Position   Assumed  in  Standing, 
with  Slight  Abduction  of  the  Right  Leg. 


Fig.  19(5.— Tilting  of  the  Pelvis  and  Abduction  of 
the  Thigh  in  Hip  Disease. 


the  knee  of  the  affected  side  is  often  flexed  slightly,  the  pelvis  being 
tipped  and  the  thigh  slightly  abducted.  The  tilting  of  the  pelvis  and 
abduction  of  the  thigh  may  be  so  slight  that  it  is  scarcely  noticeable, 
except  by  the  deviation  from  the  median  line  of  the  fold  between  the  two 
buttocks.  In  girls  the  vulva  on  the  affected  side  may  be  lower  than  on 
the  other  side. 

Pain  at  this  stage  is  very  often  absent,  and  if  present  is  noted  as  night 
cries,  to  which  allusion  will  be  made. 


HIP   DISEASE.  213 

It  has  been  customary  to  divide  hip  disease  into  stages  and  to  ascribe 
to  these  stages  certain  definite  symptoms.  Neither  from  a  clinical  nor 
a  pathological  standpoint  is  it  desirable  to  attempt  any  such  division. 

In  the  early  part  of  the  disease,  pain  at  night,  stiffness,  and  limping 
are  the  chief  symptoms.  Then  follow  malpositions  of  the  limb,  more 
severe  disability,  and  perhaps  greater  pain  and  sensitiveness.  Abduction 
of  the  diseased  limb  is  a  little  the  most  common  of  the  malpositions  of  the 
early  stage,  but  adduction  is  by  no  means  uncommon  as  an  early  symp- 
tom. Later  in  the  course  of  the  affection 
adduction  is  more  frequent  than  abduction. 

Succeeding  the  deformities  which  have 
just  been  described,  one  may  find  abscess 
formation  and  the  development  of  sinuses; 
and  this  stage  of  the  affection  will  hardly 
have  been  reached  without  considerable  con- 
stitutional deterioration,  which  may  become 
severe. 

Lameness. — From  being  at  first  scarcely 
perceptible,  the   lameness  increases  and   the  / 

limp  becomes  very  noticeable.  In  very  acute 
cases    pain  may   become   so    severe  that  the 

child  will  refuse  to  use  the  leg,  or  malposi-  i 

tion  of  the  leg  may  come  on  rapidly  and  the 
limp  may  on  that  account  become  excessive ; 
but  in  general  the  child  walks  without  pain, 

though  perhaps    limping   badly.      Until  the  / 

late  stages  of  the  disease  lameness  is  not 
due  to  bone  shortening. 

Pain. — As  the  affection  progresses,  pain         ,    --.  .'  |S 

iu  the  knee  and  sensitiveness  to  jarring  the 

limb  may  become  prominent  symptoms.  An  ^  197>_Flexion  and  Abduction. 
unconscious  protection  of   the  joint  may  be  (From  a  photograph.) 

noticed  in  the  movement  of  the  patient ;    the 

foot  of  the  well  limb  may  be  placed  under  the  lower  part  of  the  other 
leg  when  it  is  to  be  suddenly  lifted  by  the  patient,  as  from  the  floor  to 
the  bed,  or  from  the  bed  to  the  floor,  or  in  moving  from  one  side  of  the 
bed  to  the  other. 

In  manipulating  the  leg  at  this  stage  pain  may  follow  the  slightest 
jar  to  the  joint,  or,  on  the  other  hand,  the  joint  may  be  perfectly  stiff  from 
muscular  spasm  and  yet  manipulation  may  be  wholly  painless.  In  other 
cases  motion  in  a  certain  arc  is  possible  without  causing  pain,  but  when 
the  limits  of  this  arc  are  reached,  further  motion  becomes  painful  or  is 
prevented  by  muscular  fixation.  The  sensitiveness  of  the  joint  may  be- 
come so  great,  when  an  acute  stage  supervenes,  that  the  slightest  move- 


214 


ORTHOPEDIC    SURGERY. 


ment  of  the  patient,  or  jar  of  the  bed  or  room,  causes  extreme  suffering. 
This  stage  may  come  suddenly  and  gradually  pass  away,  the  pain  di- 
minishing by  degrees  under  the  enforced  treatment  of  rest,  or  it  may 
be  persistent.  A  characteristic  position  is  frequently  taken  by  the  pa- 
tient, who  places  the  Avell  foot  on  the  dorsum  of  the  foot  of  the  affected 
limb,  exerting  pressure  away  from  the  acetabulum.  Pain  may  be  absent 
at  any  or  all  stages  of  the  disease,  and  is  not  a  diagnostic  sign  for  or 
against  the  presence  of  hip  disease.  Sensitiveness  may  be  absent,  upon 
which  condition,  however,  at  any  time  a  sensitive  condition  of  the  joint 
may  supervene.  The  pain  is  often  remittent,  and  here,  as  in  all  the 
symptoms  of  this  affection,  marked  remissions  may  occur.  The  location 
of  the  pain  is  variable,  but  is  generally  referred  to  the  inside  and  front 


Fig.  198.— Instinctive  Effort  at  Traction  in  Acute  Disease  of  the  Left  Leg.     (Fiske  Prize  Fund  Essay.) 

of  the  thigh  near  the  knee  or  directly  at  the  knee-joint.  The  intimate 
relations  and  anastomoses  of  the  sciatic,  obturator,  and  anterior  crural 
nerves  seem  to  furnish  the  best  explanation  of  this. l 

Attempts  have  been  made  to  differentiate  the  varieties  of  hip  disease 
by  the  location  of  the  pain,  but  no  reliance  can  yet  be  placed  upon  such 
a  classification. 

In  a  minority  of  cases  the  pain  is  referred  to  the  joint  itself.  In  the 
more  acute  cases  sensitiveness  to  pressure  on  the  trochanter  and  to  deep 
pressure  over  the  anterior  surface  of  the  joint  (just  below  the  anterior 
superior  spme  of  the  ilium)  is  present. 

Night  Cries. — At  an  early  stage  of  the  affection  the  symptoms  of 
"  night  cries  "  often  appear.  They  occur  in  the  early  part  of  the  night 
usually,  and  may  become  an  annoying  symptom.  After  the  patient  is 
asleep,  and  to  all  appearance  entirely  unconscious,  sleep  will  be  inter- 
rupted by  a  cry  as  if  of  severe  pain,  followed  by  moaning  or  crying  for  a 
few  seconds ;  the  child  being  unconscious  or  only  half-conscious  of  the 
cause  of  the  pain.  These  do  not  often  occur  when  the  patient  is  entirely 
awake,  and  are  caused  by  the  spasmodic  twitching  of  the  muscles  abnor- 

>G.  A.  Wright:  "Hip  Disease  in  Childhood,"  p.  3U. 


J 1 1 L*   DISEASE.  215 

mally  excitable  from  irritation  reflex  to  the  inflammation  of  the  joint. 
These  cries  may  be  repeated  fifteen  or  twenty  times  during  the  night. 
They  do  not  occur  in  the  latest  stages  of  the  disease,  and  may  be  entirely 
wanting  in  the  mildest  cases.  They  resemble  somewhat  the  cry  in  the 
"  night  terrors  "  of  nervous  children,  but  differ  from  those  in  that  there 
is  greater  evidence  of  extreme  pain,  and  no  connection  with  unpleasant 
dreams,  apprehension,  or  fright.  From  the  testimony  of  patients  old 
enough  to  explain  symptoms,  the  pain  is  reported  to  be  extremely  sharp 
and  severe,  suddenly  interrupting  sleep  and  awakening  one,  and  leaving 
an  ill-defined  sense  of  an  aching  in  the  thigh  and  hip  as  if  the  hip  bad 
sustained  a  blow. 

Muscular  fixation  is  always  present  in  some  degree,  restricting  the 
joint's  normal  arc  of  motion.  It  is  due  to  a  reflex  irritability  of  the 
muscles  controlling  the  joint  which  causes  them  to  maintain  a  condition 
of  tonic  spasm  of  greater  or  less  degree.  This  will  be  discussed  more 
fully  under  the  head  of  diagnosis.  Here  it  may  be  said  that  rest  to  the 
joint  and  thorough  treatment  tend  in  time  to  restore  motion  to  the  dis- 
eased part,  and  that  if  a  child  is  taken  under  treatment  with  a  joint  per- 
fectly rigid  from  this  cause  it  is  to  be  expected  that  under  treatment  the 
joint  will  become  more  movable  unless  the  disease  is  very  acute.  In- 
creased stiffness  appearing  in  the  course  of  treatment  is  a  sign  of  ineffi- 
cient treatment  or  of  increase  of  the  disease.  This  muscular  rigidity  is 
the  most  important  sign  of  the  disease,  for  not  only  is  it  the  chief  reliance 
in  the  matter  of  diagnosis,  but  it  is  the  cause  of  the  malpositions  of  the 
limb,  of  the  wearing  away  of  the  acetabulum  and  of  the  head  of  the  bone, 
and  it  lies  at  the  root  of  much  of  the  pain.  It  furnishes  the  most  accu- 
rate index  of  the  progress  of  the  case,  and  improves  or  becomes  worse  as 
the  case  becomes  better  or  worse.  The  importance  of  the  recognition  and 
accurate  study  of  this  symptom  cannot  be  overestimated. 

A.  symptom  of  acute  hip  disease  which  has  not  received  due  attention 
is  a  muscular  irritability  of  the  lower  erector  spinee  muscles  as  well  as  of 
the  muscles  directly  controlling  the  hip-joint.  If  a  child  with  a  severe 
hip  disease  be  laid  on  his  face  and  lifted  by  the  legs  with  a  view  to 
determining  the  flexibility  of  the  lumbar  spine,  one  can  often  notice  the 
lumbar  muscles  stand  out  like  cords,  and  hold  the  lumbar  spine  quite 
rigid.  This  often  gives  rise  to  the  suspicion  of  the  coexistence  of  Pott's 
disease.  This  symptom  is  present  only  in  the  severer  forms  of  hip 
disease. 

Atrophy.— A  marked  atrophy  of  the  muscles  of  the  thigh,  hip,  and  leg 
is  characteristic.     It  is  supposed  to  be  reflex  to  the  disease  of  the  joint. ' 

Atrophy  of  the  muscles  controlling  an  inflamed  joint  begins  early  and 
may  be  very  marked,  even  in  simple  acute  synovitis.     That  this  is  some- 

1  Einile  Valtat:  "L'Atrophie  Muse,  dans  les  Mai.  Articulaires,"  Paris. 


216 


ORTHOPEDIC    SURGERY, 


thing-  more  than  the  mere  atrophy  of  disuse  is  shown  by  the  fact  that  it 

begins  so  sharply  and.  so  early,  that  it  is  greater  in  the  diseased  limb  than 

in  the  well  one  even  when 
the  patient  has  been  in  bed 
from  the  first,  and  that  the 
muscles,  although  atrophied, 
ai  e  not  soft  and  flabby,  but 
tense.  Valtat  injected  the 
joints  of  guinea-pigs  and 
dogs  with  irritant  solutions, 
mustard  oil  and  ammonia, 
and  found  that  muscular 
atrophy  came  on  quickly.  In 
one  case,  in  eight  days  there 
had  been  a  loss  of  thirty- 
two  per  cent  by  weight  in 
the  anterior  thigh  muscles, 
and  twenty -four  per  cent  in 
the  anterior  calf  muscles; 
in  auother  case  it  reached 
forty -four  per  cent,  and  in 
all  cases  the  extensors  wast- 
ed more  rapidly  than  the 
flexors.  He  attributes  much 
influence  in  the  matter  to 
the  amount  of  pain  present, 
a  point  already  clinically 
noted  by  Paget.  Valtat  also 
calls  attention,  in  this  con- 
nection, to  the  paralysis  of 

the  muscles  of  the  affected  limb  often  accompanying  acute  joint  disease. 

In  a  case  of  knee-joint  synovitis,  which  he  mentions,  there  was  complete 


Fig.  199.— Severe  Flexion  in  Hip  Disease.    (Fiske  Prize 
Fund  Essay.) 


Fig.  200.— Severe  Abduction  and  Inversion  in  a  very  Acute  Case. 


paralysis  of  the  flexors  of  the  leg  at  the  end  of  twenty-four  hours.     Such 
a  paralysis,  to  a  greater  or  less  degree,  seems  to  precede  the  wasting  of 


HIP    DISK  ASK. 


217 


the  muscles.  It  may  be  noted  here  that  increased  patellar  reflex  U  gener- 
ally present  in  the  affected  leg  during  the  early  part  of  the  disease  and 
that  the  thigh  muscles  show  a  diminished  contractility  to  the  faradic 
current. 

This  atrophy  generally  can  be  easily  appreciated  at  an  early  stage  <<! 
the  disease  by  grasping  the  muscles  in  the  hand  or  by  measurement  with 
a  tape.  The  difference  in  the  circumference  of  the  two  thighs  will  be 
perhaps  one-quarter  of  an  inch  to  an 
inch,  and  the  difference  in  the  size 
of  the  calves  is  generally  about  half 
of  the  thigh  difference.  In  children 
who  can  use  the  leg  fairly  well  there 
is  rarely  any  calf  atrophy  at  the  first 
examination.  The  obliteration  of 
the  fold  of  the  buttock  on  the  af- 
fected side  is  a  result  partly  of 
muscular  atrophy  and  partly  of  the 
peri-articular  swelling  which  accom- 
panies the  disease.  It  is  a  common 
but  not  a  constant  symptom  at  the 
early  stages  of  the  disease.  It  is 
also  partly  due  to  the  flexed  attitude 
of  the  limb,  which  naturally  dimin- 
ishes the  prominence  of  the  buttock 
on  that  side. 

3J  a /positions  of  the  Limb. — The 
fixation  of  the  diseased  limb  in  a 
distorted  position  is  one  of  the  com- 
monest incidents  of  the  affection. 
This  is  due  to  the  tonic  muscular 
contraction  so  often  alluded  to. 
These  malpositions  may  hold  the 
limb  in  flexion,  adduction,  abduction, 
or  eversion,  or  in  any  combination 
of  these ;  the  cause  which  determines 

the  kind  of  malposition  in  an  individual  case  cannot  be  formulated. 
Flexion  of  the  thigh  was  originally  supposed  to  be  due  to  an  effusion  in 
the  capsule  of  the  hip-joint,  but  it  is  seen  along  with  adduction  and  ab- 
duction in  cases  in  which  no  effusion  has  taken  place.  It  is  chiefly  due  to 
the  muscular  contraction,  which  is  constant  in  chronic  disease  of  the  joint, 
and  partly  to  an  unconscious  effort  on  the  part  of  the  patient  to  assume  a 
position  most  comfortable  for  the  joint  and  most  protected  from  jar. '    This 

1  Lannelongue :    "Coxotubercuiose."  Paris,    188-3,    Hilton:   "Rest   ami   Pain." 
London. 


Flu.  301.— Flexion  and  Adduction  of  Left  Leg. 
(Fiske  Prize  Fund  Essay.) 


21 S 


ORTHOPEDIC    SURGERY 


fact  has  been  alluded  to  by  Sherman,  of  .San  Francisco, '  deformity  being 
largely  due  in  his  opinion  to  the  unconscious  assumption  on  the  part  of 
the  patient  of  the   position  most  protected  from  joint  strain  or  injury. 


Fig.  208.—  Adduction  of  the  Left  Leg  in  Acute  Hip  Disease 

These  deformities  generally  disappear  under  treatment  by  rest  or  trac- 
tion ;  but  again,  they  reappear  in  cases  under  treatment  if  treatment  has 
not  succeeded  in  checking  the  progress  of  the  disease,  and  they  go  hand- 


FiG.  303.— Lordosis  Resulting  from  Bringing  the  Flexed  Leg  in  Hip  Disease  Parallel  to  the  Other. 

in-hand  with  a  sensitive  condition  of  the  joint  which  may  be  the  pre- 
cursor of  abscess. 

If  the  malposition  is  allowed  to  become  permanent  the  final  result  can 
never  be  so  good  as  when  cicatrization  takes  place  in  a  more  normal  posi- 
tion. The  limp  in  ankylosed  limbs  depends  more  upon  the  amount  of  flex- 
ion and  adduction  than  on  anything  except  perhaps  the  bone  shortening. 


1  Orth.  Trans.,  vol.  xii. 


HIP   DISEASE.  210 

It  is,  therefore,  of  much  importance  to  diminish  in  all  cases  the  amount 
of  malposition  present. 

When  adduction  is  present  in  both  legs,  as  in  double  hip  disease,  and 
ankylosis  of  both  hips  has  occurred,  cross-legged  progression  is  made 
necessary  on  account  of  the  inability  to  separate  the  legs. 

The  position  in  standing  and  lying  is  modified  by  the  occurrence  of 
these  malpositions ;  abduction  or  adduction  causes  tilting  of  the  pelvis 
and  flexion  causes  a  marked  lordosis  of  the  lumbar  spine  in  standing 
with  the  legs  parallel;  by  standing  with  the  diseased  leg  ^.somewhat 
flexed  the  lordosis  can  be  overcome.  The  same  arching  of  the  lumbar 
spine  occurs  when  the  patient  lies  on  a  table  and  the  flexed  leg  is  brought 
down. 

Peri-articular  Symptoms.- — A  density  in  the  superficial  tissues  over  a 
diseased  hip  which  the  other  side  does  not  possess  is  often  found  at  a 
comparatively  early  stage  of  the  affection.  Behind  or  in  front  of  the 
trochanter  the  deep  tissues  are  resistant  and  the  fossa  existing  there  is 
filled  out,  and  the  great  trochanter  feels  enlarged  and  thicker  than  its 
fellow  when  grasped  by  the  fingers  deeply  pressed  in. 

The  inguinal  glands  of  the  affected  side,  sometimes  of  both  sides,  are 
often  enlarged  and  they  may  be  so  much  distended  that  they  obstruct  the 
venous  return  and  the  skin  may  be  marbled  with  superficial  veins.  They 
are  at  times  the  seat  of  superficial  abscesses.  In  very  severe  cases  the 
upper  part  of  the  thigh  and  the  tissues  in  the  vicinity  of  the  hip  may 
become  swollen  generally  from  an  oedema  of  the  periarticular  tissues. 
This  may  disappear  or  become  localized  in  the  formation  of  an  abscess. 
A  thickening  over  the  tensor  vaginae  femoris  is  often  to  be  felt. 

Abscess.  — In  a  proportion  of  cases  suppuration  takes  place.  The  site 
and  course  of  the  abscesses  vary  according  to  the  seat  and  size  of  the 
original  focus  of  the  ostitis,  whether  in  the  femur  or  acetabulum.  Ab- 
scesses may  be  entirely  peri-articular,  if  the  initial  lesion  of  the  epiphysis 
extend  in  a  course  outside  of  the  joint;  or  they  may  come  from  suppura- 
tion within  the  joint;  or  having  been  peri-articular,  they  may  later 
involve  the  joint. 

The  invasion  of  the  abscess  is  frequently  without  constitutional  dis- 
turbance, exacerbation  of  pain  and  joint  symptoms  is,  however,  a  fre- 
quent accompaniment  of  this  formation.  Abscesses  may  be  absorbed  or 
may  evacuate  themselves  spontaneously  either  completely  or  partially, 
tho  residual  fluid  following  along  the  course  of  the  sheaths  of  the  muscles 
and  the  fasciae,  reappearing  later  as  secondary  abscesses,  the  same  abscess 
causing  five  or  six  fistulous  openings.  These  openings  discharge  pus  and 
serum  for  months  and  years  in  most  cases.  These  sinuses  after  a  short 
time  become  infected  with  pyogenic  organisms.  With  the  bursting  of  an 
abscess  and  the  discharge  of  any  considerable  quantity  of  pus  the 
patient's  condition  may  show  rapid  improvement,  or  if  imperfect  drain- 


220  ORTHOPEDIC    SURGERY. 

age  takes  place,  reappearance  of  the  abscess  may  occur  and  the  patient's 
condition  may  become  worse. 

When  the  pus  has  left  the  joint  it  generally  burrows  between  the 
thigh  muscles  to  reach  the  skin,  where  it  appears  as  a  swelling  of  varying 
size.  Fluctuation  is  usually  marked.  As  the  abscess  invades  the  skin 
the  latter  becomes  thin  and  red,  and  ulcerates  in  one  or  two  places, 
evacuating  the  abscess.  The  contents  of  the  abscess  may,  however,  in  a 
few  instances  be  absorbed  even  at  a  stage  when  fluctuation  is  marked, 
and  the  swelling  may  disappear,  perhaps  leaving  a  depression  beneath 
the  skin. 

The  pus  most  commonly  reaches  the  skin  at  the  anterior  border  of  the 


Fig.  204.— Hip  Abscess,  with  Deep  Fluctuation  at  the  Anterior  and  Upper  Part  of  the  Thigh.    (Fiske 

Prize  Fund  Essay.) 

tensor  vaginae  f emoris  muscles ;  it  may,  however,  gravitate  backward  and 
open  back  of  the  great  trochanter  or  at  the  lower  border  of  the  glutaeus 
maximus;  it  may  come  around  to  the  inner  side  of  the  thigh  and  perhaps 
open  in  front  of  the  adductor  tendons  or  even  discharge  into  the  rectum; 
finally,  it  may  ascend  the  sheath  of  the  psoas  muscles  and  point  above 
Poupart's  ligament,  or  it  may  descend  in  the  thigh  muscles  and  point  in 
the  popliteal  space.  It  has  been  said  that  the  seat  of  the  primary  dis- 
ease can  be  inferred  by  the  situation  of  the  abscess,  but  enough  facts 
have  not  yet  been  obtained  to  justify  such  a  generalization. 


IFir   DISEASE. 


■/■> 


Probably  abscess  Is  very  often    the  result  of    inefficient  treatment. 
This  has  been  the  experience  at  the  Boston  Children's  Hospital.1     As  the 


FIG.  205.— Deformity  in  Untreated  Double  Hip  Disease. 

treatment  has  become  more  thorough  the  number 
of  abscesses  has  diminished. 

Shortening.  — The  effect  of  persistent  muscular 
spasm  of  muscles  about  the  hip- joint,  character- 
istic of  hip  disease,  is  to  crowd  the  femur  against 
the  acetabulum  and  to  produce  the  enlargement 
of  the  acetabulum  and  the  absorption  of  the 
head  of  the  femur,  with  resulting  shorten- 
ing of  the  limb. 

In  addition  to  the  shorten-  -  . 

ing  produced  by  absolute   de-     j'J§H 
struction  of  bone  in  the  femur 
or  the  acetabulum,  there  is  a  "%;-- 

decided  trophic  disturbance  of 
the  limb  which  results  in  retarding 
the  bony  growth  and  probably  causes 
at  the  same  time  a  certain  amount 
of  bone  atrophy  ;  retarded  growth  of 
the  affected  limb  becomes  evident  in 
the  early  months  of  the  disease,  and 
is  a  permanent  condition  which  is 
not  outgrown  as  years  go  on,  for  the  \ 
affected  limb  always  lags  behind  the 

Other  in  its  growth.  Fig^06. -Position  Necessitated 

°  nent  Mexion  Deformity  Resu  kin; 

The    shortening   may   be  evenly      Hip  Disease. 


X 


by  the 
»  from 


Perina- 
Double 


1  Lovett  and  Goldthwait  .  Ortho.  Trans  .  vol.  ii..  p.  82. 


222 


ORTHOPEDIC    SURGERY. 


distributed  between  the  bones  of  the  leg  and  those  of  the  thigh,  or  it 
may  be  most  marked  in  the  bones  of  the  leg.  When  there  is  much 
shortening  of  the  leg,  the  foot  of  the  affected  side  is  also  smaller  than 
the  other.  The  difference  in  the  length  of  the  legs  almost  always  in- 
creases slightly  after  the  disease  is  cured,  as  was  shown  in  the  series 
of  cured  cases  of  hip  disease  analyzed  by  Shaffer  and  Lovett.' 

General   Condition. — Children  with  hip  disease  are  often  robust  at  the 
besnnninar  of  the  affection  and  sometimes  the  general  condition  continues 


Fig.  207.— Progression  in  a  Case  of  Severe  Double  Hip  Disease. 

good  to  the  end,  but  these  cases  are  exceptional.  More  often  the  child 
is  pale  and  the  appetite  fails  at  times ;  there  is  often  loss  of  flesh  j  in 
some  mild  cases  and  in  most  of  the  severe  ones  decided  constitutional 
disturbance  results. 

Remissions. — Any  account  of  the  symptoms  of  hip  disease  would  be 
incomplete  without  speaking  of  the  remissions  in  the  course  of  the  affec- 
tion. In  the  early  stage  this  is  especially  noticeable,  and  a  patient  may 
to  outside  appearances  entirely  recover  from  the  symptoms  of  pain,  lame- 
ness, and  discomfort  for  some  days  or  weeks,  Then  the  symptoms  re- 
turn with  increased  vigor,  perhaps  to  disappear  again  in  a  short  time. 
The  muscular  stiffness  does  not  wholly  disappear  at  these  times,  although 
it  may  improve  along  with  the  other  manifestations  of  the  disease. 
The  later  course  of  the  disease  is  marked  by  much  greater  uniformity, 
but  even  then  temporary  improvement  may  be  quite  marked. 


N.  Y.  Med.  Jour.,  May  21st,  1887. 


HIP  DISEASE.  223 

Temperature. — Children  with  hip  disease  under  treatment  by  ambula- 
tory measures  have  as  a  rule  a  higher  afternoon  temperature  than  normal. 
In  627  observations  made  on  cases  of  hip  disease  and  Pott's  disease  at 
the  Out-Patient  Department  of  the  Children's  Hospital  a  rise  of  tempera- 
ture of  one  or  two  degrees  was  common.  Ninety  per  cent  of  all  cases, 
acute  or  chronic,  mild  or  severe,  had  an  evening  temperature  of  at  least 
99°,  and  a  rise  to  103°  or  104*°  in  severe  cases  was  not  necessarily  an 
indication  of  abscess. 

Double  Hip  Disease. — The  disease  seldom  begins  in  both  hip- joints  at 
the  same  time,  and  the  second  joint  may  become  inflamed  while  the  pa- 
tient is  under  treatment  in  bed  for  the  first  joint. 

The  course  of  double  hip  disease  would  appear  to  vary  somewhat  from 
that  of  single  hip  disease.  The  amount  of  pain  suffered  in  the  joint  last 
affected  is  usually  less  than  that  of  the  first  joint,  probably  because  there 
is  less  jar  or  motion  when  two  hip- joints  are  affected  than  when  one  is. 

Malpositions  are  more  than  usually  troublesome  and  may  be  different 
in  the  two  hips.  Kecovery  without  deformity  and  with  as  much  motion 
as  possible  is  most  important  in  double  hip  disease. 

Diagnosis. 

The  diagnosis  of  hip  disease  may  be  easy  or  difficult;  in  the  earliest 
stages,  errors  in  it  are  sometimes  made,  and  care  is  necessary  for  a  posi- 
tive diagnosis  in  any  stage.  The  most  common  error  is  the  belief  that 
the  presence  of  pain  or  tenderness  is  necessarily  present  in  hip  disease, 
and  that  its  absence  excludes  the  possibility  of  hip  disease.  Another 
error  often  made  is  to  look  for  " grating"  in  the  joint  as  a  sign  of  the 
disease.  That  sign  is  to  be  obtained  only  by  the  use  of  an  anaesthetic  by 
which  means  the  muscles  guarding  the  joint  are  relaxed  and  then  only  in 
advanced  cases  when  two  bony  and  eroded  surfaces  lie  in  contact. 

The  diagnostic  symptoms  in  hip  disease  which  should  be  borne  in 
mind  in  making  a  diagnosis  of  hip  disease  are  as  follows : 

1.  Muscular  spasm  (stiffness  of  the  joint  or  limitation  of  its  motion). 

2.  Lameness. 

3.  Attitude  of  the  limb  standing,  or  walking,  or  lying  (adduction  and 
abduction  of  the  limb) ,  and  shortening. 

4.  Atrophy. 

5.  Swelling. 

These  symptoms  vary  in  prominence  at  different  stages  of  the  disease. 

It  may  be  said  that  the  early  diagnosis  must  be  made  chiefly  by  the 
symptom  of  muscular  rigidity.  The  absence  of  pain  or  sensitiveness 
counts  for  nothing  and  atrophy  is  not  characteristic.  The  limp  is  pecu- 
liar, but  a  similar  one  is  present  in  other  conditions. 

Muscular  Sjmsm. — The  chief   diagnostic  sign  in  hip    disease,   upon 


224 


ORTHOPEDIC    SURGERY. 


which  the  chief  reliance  must  always  be  placed,  is  the  presence  of  stiffness 
of  the  joint  or  limitation  of  its propbr  arc  of  motion  when  the  limb  is  pas- 
sively manipulated.  Except  in  the  very  earliest  stages  there  can  be  no* 
hip  disease  without  a  perceptible  limitation  of  motion.     This  limitation 


Fig.  208.— Method  of  Examining  Hip. 

of  motion  is  not  the  result  of  adhesions  or  beginning  ankylosis  in  early 
hip  disease,  but  it  is  the  result  of  a  tonic  contraction  of  the  muscles  con- 


FiG.  209.— Method  of  Determining  the  Limitation  of  Extension  in  Hip  Disease. 


trolling  the  joint,  and  disappears  under  anaesthesia  in  the  early  stages  of 
the  disease. 

In  the  detection  of  this  most  important  diagnostic  sign  it  should  be 
borne  in  mind  that  some  care  is  required  to  discover  slight  limitation  of 
motion  in  very  young  children,  who  are  apt  to  resist  thorough  examina- 
tion.     The  voluntary  resistance  to  manipulation  due  to  fright  is,  how- 


HIP    DISEASE.  225 

ever,  always  resistance  to  all  motions  of  the  limb;  if  by  slight  force  this 
is  overcome,  resistance  to  any  especial  motion  will  not  be  encountered 
unless  hip  disease  is  present.  A  comparison  of  the  resistance  of  one  leg 
with  that  of  the  other  will  reveal  abnormal  resistance.  The  normal 
amount  of  abduction  is,  however,  slight,  and  resistance  to  motion  in  this 
direction,  therefore,  is  an  early  test  of  importance.  Extreme  abduction 
and  rotation  of  the  thigh  flexed  at  right  angles  to  the  body  are  delicate 
tests. 

In  young  and  frightened  children,  the  tests  for  limitation  of  motion  at 
the  hip-joint  are  best  made  with  the  children  lying  on  the  mother's  lap 
or  leaning  on  the  mother's  shoulder.  In  examining  older  children  for 
muscular  stiffness,  the  clothes  should  be  removed  and  the  patients  should 
lie  upon  a  hard  surface  rather  than  on  a  bed.  Attempts  to  move  the  limb 
should  be  made  gradually,  gently,  and  persistently — rough  force  only  ex- 
citing resistance  and  making  a  delicate  examination  impossible.  It  is 
advisable  first  to  put  the  normal  leg  through  the  same  manipulations 
which  are  to  be  made  on  the  affected  side.  The  most  convenient  order  of 
motion  in  examination  is  first  flexion,  then  abduction  and  abducting  rota- 
tion with  the  thigh  flexed,  then  extension.  The  suspected  limb  should 
be  held  at  the  ankle  or  knee  with  one  hand,  while  the  other  hand  will 
grasp  the  pelvis  to  ascertain  when  motion  in  the  joint  ceases  and  move- 
ment of  the  pelvis  begins.  Examination  under  anaesthesia  shows  noth- 
ing, at  the  early  stage  of  hip  disease,  as  muscular  spasm,  the  most  im- 
portant diagnostic  sign,  has  been  overcome  and  is  absent. 

A  limitation  to  flexion  is  determined  by  flexion  of  the  normal  limb  on 
the  abdomen  to  its  utmost  limit,  and  afterward  a  repetition  of  the  motion 
of  the  suspected  limb.  If  the  limb  is  then  extended  so  that  the. popliteal 
space  be  placed  upon  the  hard  surface  on  which  the  patient  lies,  normally 
there  will  be  no  alteration  of  the  position  of  the  back;  if,  however,  there 
is  a  limitation  in  the  normal  extension  of  the  limb,  the  back  will  be 
arched  up  as  the  popliteal  space  is  pressed  down.  This  limitation  of  ex- 
tension can  also  be  determined  by  examining  the  patient  lying  upon  the 
belly.  If  one  hand  be  placed  on  the  sacrum  and  the  thighs  be  alternately 
raised  from  the  surface  on  which  the  patient  lies,  a  difference  in  the  amount 
of  motion  at  the  hip  without  moving  the  sacrum  can  easily  be  determined. 
The  limit  to  the  amount  of  abduction  or  adduction  is  determined  by  plac- 
ing one  hand  on  the  anterior  superior  spine  of  the  ilium  on  the  sound  side, 
and  with  the  other  hand  gently  abducting  or  adducting  the  suspected 
limb;  when  limitation  is  present  the  pelvis  of  course  moves  with  the 
diseased  limb.  Eor  detecting  limitation  of  rotation  the  thigh  should 
be  flexed  to  a  right  angle  and  rotation  tested  in  that  position.  The 
motions  most  often  limited  in  early  hip  disease  are  abduction,  ex- 
tension, and  rotation.  The  loss  of  motion  in  this  group  is  always  sug- 
gestive. 

15 


226 


ORTHOPEDIC    SURGERY 


Careful  inspection  in  the  early  stages  of  hip  disease  during  manipula- 
tion will  sometimes  show  fibrillary  contraction  of  the  muscles  of  the  thigh 
on  sudden  or  unexpected  movement  of  the  limb. 

In  the  later  stages  of  hip  disease  complete  stiffness  of  the  joint  may 
be  present.  This  is  due  to  muscular  spasm  and  disappears,  in  a  meas- 
ure at  least,  under  complete  anaesthesia,  unless  a  fibrous  ankylosis  of  the 
hip  joint  has  begun  to  develop. 

It  is  not  possible  to  say  just  what  degree  of  muscular  spasm  on  the 
part  of  the  muscles  can  be  accepted  as  evidence  of  disease  of  the  joint. 

Any  catch  in  the  motion  of  the  joint  in  any 
part  of  its  arc  is  exceedingly  suspicious,  no 
matter  how  slight  it  may  be. 

Lameness. — At  the  earliest  stages  the  limp- 
ing may  be  intermittent  and  not  constant,  and 
again,  it  may  be  so  slight  that  it  is  practically 
imperceptible,  so  that  its  absence  does  not  ex- 
clude hip  disease.  Its  character  has  been  al- 
ready described,  and 

the    fact   that    it   is  **x-  Tl»2 

worse  in  the  morning 
than  at  night,  but 
these  are  not  alto- 
g  e  t  h  e  r  distinctive 
and  the  diagnosis 
cannot  be  made  alone 
from  watching  the 
child  walk. 

Attitudes.  —  A  b- 
normal  positions  of 
the  diseased  limb  at 
an  early  stage  of  the 
disease  are  caused 
by  the  action  of  the 
muscles  holding  the 
limb  stiffly  in  dis- 
torted position.  Neither  adduction  or  abduction  of  the  limb  is  usually 
recognized  by  the  patient  as  such,  but  the  complaint  is  made  that 
the  limb  seems  longer  or  shorter  than  the  other.  The  pelvis  is  tilted, 
which  gives  a  practical  lengthening  of  the  limb  if  abduction  is  present, 
and  in  the  same  way  the  limb  appears  shorter  to  the  patient  if  adducted. 
The  tilting  of  the  pelvis  can  be  recognized  by  drawing  a  line  from  the 
anterior  superior  spine  of  one  side  to  that  of  the  other.  This  should 
normally  be  at  right  angles  with  a  line  from  the  umbilicus  to  the  sym- 
physis pubis.     In  this  way  have  arisen  the  terms  of  apparent  or  jwactical 


Fig.  210.  —  Diagram  Showing 
Practical  Shortening  from  Ad 
duction. 


Fig.  SI  1.— Diagram  Showing 
Apparent  Shortening  and 
Lengthening  of  Leg  due  to  Tilt- 
ing of  the  Pelvis. 


HIP   DISEASE.  227 

shortening  and  lengthening,  which  have  given  rise  to  some  obscurity,  being 
often  confused  with  real  or  bony  shortening. 

The  accompanying  diagrams  will  explain  the  matter.  The  normal 
position  of  the  pelvis  in  relation  to  the  limbs  is  shown  in  heavy  lines  in 
Fig.  1,  where  both  legs  are  at  right  angles  to  the  pelvis,  the  normal  posi- 
tion for  standing  and  walking.  If,  however,  the  right  leg  is  fixed  by 
muscular  spasm  in  anadducted  position,  AE,  the  relation  is  changed,  and 
when  the  patient  stands  erect  the  legs  must  be  made  parallel  to  permit 
walking  or  standing  on  both  feet,  and  this  can  be  done  only  by  tilting  the 
pelvis  to  the  position  shown  in  Fig.  2.  It  will  be  seen  by  the  tilting 
that  the  leg  AC  is  carried  up  with  that  side  of  the  pelvis  and  to  all  ap- 
pearances the  leg  AC  is  shorter  than  the  leg  BD,  when  the  patient  stands 
or  lies  straight.  Thus  adduction  results  in  apparent  shortening  of  the 
adducted  limb  as  compared  with  the  other  when  the  patient  lies  straight. 
In  the  same  way  in  Fig.  3,  if  the  leg  AC  is  abducted  to  the  position  AF, 
the  pelvis  must  be  tilted  in  the  opposite  direction  to  make  the  legs  paral- 
lel, because  the  angle  FAB  is  a  fixed  quantity,  and  so  the  pelvis  is 
tilted,  and  A  C  for  practical  purposes  is  longer  than  BD,  and  the  amount 
of  apparent  lengthening  depends  upon  the  amount  of  abduction. 

A  patient  then  with  fixation  of  one  leg  in  a  position  of  adduction  has 
a  deformity  which  results  in  a  lifting  of  that  leg  from  the  ground  when 
he  stands  or  walks,  for  the  tilting  of  the  pelvis  has  caused  a  practical 
shortening  of  that  leg.  In  the  same  way  abduction  causes  the  opposite 
tilting  of  the  pelvis  and*a  practical  lenthening  of  the  diseased  leg.  So 
that  the  term  apparent  or  practical  shortening  can  be  applied  to  the 
inequality  of  the  legs  noticed  in  walking  or  standing,  which  results  from 
the  tilting  of  the  pelvis.  Practical  shortening  can  be  estimated  by  meas- 
uring from  the  umbilicus  to  each  malleolus  when  the  patient  lies  or  stands 
straight. 

Real  or  bone  shortening  is  different  from  apparent  shortening.  It  re- 
sults from  the  retarded  growth  or  atrophy  of  the  affected  limb  or  from 
the  destruction  of  bone  in  the  hip-joint,  and  is  independent  of  the  amount 
of  adduction  or  abduction.  Real  shortening  is  measured  by  a  tape  from 
the  anterior  superior  spines  of  the  ilium  to  the  malleolus  on  each  side. 

It  is  important,  in  an  examination  for  hip  disease,  to  determine  the 
amount  of  permanent  joint  injury  which  the  disease  has  already  inflicted. 
The  amount  of  enlargement  of  the  acetabulum  and  absorption  of  the  head 
of  the  femur  which  has  taken  place,  may  be  estimated  by  determining 
the  amount  that  the  trochanter  of  the  femur  has  risen  above  its  normal 
position.  If  the  patient  lie  upon  the  well  side,  and  Nelaton's  line  (from 
the  anterior  superior  spine  to  the  most  prominent  part  of  the  tuberosity 
of  the  ischium) ,  be  drawn  over  the  affected  hip,  the  thigh  being  somewhat 
flexed  it  should  pass  just  above  the  upper  margin  of  the  trochanter; 
if  the  trochanter  is  above  this  line,  it  is  an  evidence  of  subluxation. 


228  ORTHOPEDIC   SURGERY. 

Estimation  of  Adduction  and  Abduction. — The  amount  of  clef ormity  due 
to  adduction  or  abduction  or  flexion  of  the  limb  is  an  important  index  of 
the  progress  or  activity  of  the  disease  and  should  be  carefully  estimated. 

This  estimation  of  the  amount  of  adduction  or  abduction  present  has 
ordinarily  been  made  by  the  use  of  the  goniometer,  an  instrument  which 
measures  the  angle  between  the  transverse  axis  of  the  pelvis  and  the  long 
axis  of  the  leg.  The  horizontal  arm  is  laid  on  the  anterior  superior  iliac 
spines  and  the  other  arm  is  then  laid  in  the  line  of  the  diseased  leg  and 
the  index  shows  the  angle  of  deformity.  This  instrument  is  clumsy  and 
not  always  at  hand.  A  simpler  method  has  been  devised  by  which  it  is 
possible  to  estimate  with  the  tape  measure  alone  the  angle  of  either  abduc- 
tion or  adduction  present. 

In  measuring  patients  it  is  found  that  real  and  practical  shortening  of 
a  leg  are  often  not  the  same  in  the  same  patient,  and  that  the  difference 
between  them  varies  in  proportion  to  the  amount  of  deformity  present. 
This  was  taken  as  the  basis  for  constructing  the  following  working  table. 
The  mathematical  process  by  which  it  was  made  is  given  in  full  in  the 
original  article.1  To  measure  by  this  method,  the  patient  is  made  to  lie 
straight,  with  the  legs  parallel.  Real  shortening  is  measured  with  the 
ordinary  tape  measure,  and  apparent  shortening  is  obtained  in  the  same 
way.  It  may  be  repeated  that  real  or  bony  shortening  is  measured  from 
the  anterior  superior  iliac  spines  to  each  malleolus,  and  that  practical  short- 
ening is  found  by  a  measurement  taken  from  the  umbilicus  to  each  mal- 
leolus. The  difference  in  inches  between  the  two  kinds  of  shortening  is 
seen  at  a  glance.  The  only  additional  measurement  necessary  is  the  dis-. 
tance  between  the  anterior  superior  spines,  which  is  taken  with  the  tape. 
Turning  now  to  the  table,  if  the  line  which  represents  the  amount  of 
difference  in  inches  between  the  real  and  apparent  shortening  is  followed 
until  it  intersects  the  line  which  represents  the  pelvic  breadth,  the  angle 
of  deformity  will  be  found  in  degrees,  where  they  meet.  If  the  practical 
shortening  is  greater  than  the  real  shortening,  the  diseased  leg  is  adducted  ; 
if  less  than  real  shortening,  it  is  abducted.  Take  an  example :  Length 
(from  anterior  superior  spine)  of  right  leg,  23;  left  leg,  22^;  length 
(from  umbilicus)  of  right  leg,  25;  left  leg,  23;  real  shortening,  4-  an 
inch,  apparent  shortening  2  inches ;  difference  between  real  and  practical 
shortening,  1-|  inches ;  pelvic  measurement,  7  inches.  If  we  follow  the 
line  for  1-^  inches  until  it  intersects  the  line  for  pelvic  breadth  of  7  inches, 
we  find  12°  to  be  the  angular  deformity,  as  the  practical  shortening  is 
greater  than  the  real,  it  is  12°  of  adduction  of  the  left  leg.  If  apparent 
lengthening  is  present  its  amount  should  be  added  to  the  amount  of 
actual  shortening. 

1  R.  W.  Lovett :  Bost.  Med.  and  Surg.  Journal,  March  8th,  188* 


HIP   DISEASE. 


229 


Tahle  I. 
Distance  between  Anterior  Superior  Spines  in  inches. 


i 
i 
f 
1 

H 
H 
"it 

2 
~2? 

at 

3 

3f 
4 

3 

3* 

4 

4* 

5 

6* 

(> 

64 

7 

n 

8 

84 

9 

!».(  10 

11 

12 

13 

5° 

4° 

4° 

3° 

3° 

2° 

2° 

2° 

2° 

2° 

2° 

2" 

2" 

1° 

1 

1 

1 

1 

10 

8 

7 

6 

5 

5 

4 

4 

4 

4 

4 

4 

4 

3 
4 

3 

4 

3 

4 

3 

2 

14 

12 

11 

10 

8 

8 

7 

7 

6 

6 

5 

5 

5 

3 

3 

19 

17 

14 

13 

11 

10 

9 

9 

8 

7 

7 

7 

6 

0 

(i 

5 

5 
6 

4 

25 

21 

18 

16 

14 

13 

12 

11 

10 

9 

9 

8 

8 

7 

7 

7 

6 

30 

25 

22 

19 

.17 

15 

14 

13 

12 

12 

11 

10 

ID 

!) 

9 

8 

7 

7 

36 

30 

26 

23 

20 

18 

17 

15 

14 

13 

13 

12 

11 

10 

10 

9 

8 

8 

42 

35 

30 

26 

23 

21. 

19 

18 

16 

15 

14 

14 

13 

12 

12 

10 

10 

'.) 

40 

34 

30 

26 

24 

21 

20 

19 

17 

16 

15 

14 

14 

13 

12 

11 

10 

39 

34 

29 

27 

24 

22 

21 

19 

18 

17 

16 

15 

14 

13 

12 

11 

38 

32 

29 

27 

25 

23 

21 

20 

19 

18 

17 

16 

14 

13 

12 

42 

35 

32 

29 

27 

25 

23 

22 

21 

19 

18 

18 

16 

14 

13 

39 

36 

32 

30 

27 

26 

25 

22 

21 

20 

19 

17 

15 

14 

40 

35 

33 

30 

28 

26 

24 

23 

22 

21 

19 

17 

16 

38 

35 

32 

30 

28 

26 

25 

23 

22 

20 

18 

17 

ww./; 

tlnti 

nf 

Fit 

nr.ini 

i. — 

42 
Thf 

38 

35 
it  inn 

32 

rip 

30 
Fnrn 

28 

26 
nf 

25 

flin 

2g 

21 

-rli   i 

19 

18 

measured  by  a  similar  method. '     The  patient  lies  upon  a  table  llat  on 


A  C 

Fig.  212.— Estimation  of  Flexion. 


his  back  and  the  surgeon  flexes  the  diseased  leg,  raising  it  by  the  foot 
until  the  lumbar  vertebrae  touch  the  table,  showing  that  the  pelvis  is  in 


1  G.  L.  Kingsley :  Bost.  Med.  and  Surg.  Jour.,  July  5th,  1888. 


230 


ORTHOPEDIC   SURGERY. 


the  correct  position.  The  leg  is  then  held  for  a  minute  at  that  angle,  the 
knee  being  extended,  while  the  surgeon  measures  off  two  feet  on  the  out- 
side of  the  leg  Avith  a  tape  measure,  one  end  of  which  is  held  on  the  table 
(so  that  the  tape  measure  follows  the  line  of  the  leg)  (AB).  From  this 
point  on  the  leg  (B)  where  the  two  feet  reaches  by  the  tape  measure  one 
measures  perpendicularly  to  the  table  (BC),  and  the  number  of  inches  in 
the  line  BC  can  be  read  as  degrees  of  flexion  of  the  thigh,  by  consulting 
Table  II.  For  instance,  if  the  distance  between  the  point  on  the  leg  and 
the  table  is  12^  inches  it  represents  31°  of  flexion  deformity  of  the  thigh. 

Table   ii. 


In. 

Dear. 

In. 

Deg. 

In. 

Peg. 

In. 

Deg. 

0.5 

1 

6.5 

16 

12.5 

31 

18.5 

50 

1.0 

■> 

7.0 

17 

13.0 

33 

19.0 

52 

1.5 

3 

7.5 

19 

13.5 

34 

19.5 

54 

2.0 

4 

8.0 

20 

14.0 

36 

20.0 

56 

2.5 

0 

8.5 

21 

14.5 

37 

20.5 

58 

3.0 

7 

9.0 

22 

15.0 

39 

21.0 

60 

3.5 

!> 

9.5 

24 

15.5 

40 

21.5 

63 

4.0 

10 

10.0 

25 

16.0 

42 

22.0 

67 

4.5 

11 

10.5 

27 

16.5 

43 

22.5 

70 

5.0 

12 

11.0 

28 

17.0 

45 

23.0 

75 

5.5 

14 

11.5 

29 

17.5 

47 

23.5 

80 

0.0 

15 

12.0 

39 

18.0 

48 

24.0 

90 

If  the  leg  is  so  short  that  it  is  impracticable  to  measure  off  twenty- 
four  inches,  one  can  measure  twelve  inches;  ascertain  from  here  the  dis- 


Fig.  213.— Thomas'  Test  for  the  Estimation  of  Flexion  of  the  Diseased  Leg  in  Hip  Disease. 

tance  to  the  surface  on  which  the  patient  is  lying  in  a  perpendicular  line 
in  the  same  way,  then  doubling  this  distance  and  looking  in  the  table  as 
before  the  amount  of  flexion  is  found. 


HIP   DISEASE.  23 i 

Thomas'  test  for  flexion  is  one  which  is  sometimes  of  use  for  a  rough 
estimation  of  the  amount  of  flexion  deformity.  The  patient  lies  on  the 
back  and  the  well  thigh  is  flexed  on  to  the  abdomen  and  held  there. 
This  places  the  pelvis  in  the  correct  position,  with  the  lumbar  spine  in 
contact  with  the  table,  and  the  diseased  thigh  is  by  this  naturally  thrown 
into  a  position  of  flexion  if  such  deformity  exists.  The  figure  (Fig.  213.) 
makes  the  method  plain.  It  is  not  suitable  for  use  in  cases  in  which  the 
hip  is  sensitive,  nor,  as  a  rule,  in  the  case  of  adults. 

Atrophy. — Atrophy  rapidly  becomes  more  marked  than  if  due  to 
simple  disuse. 

The  measurement  for  atrophy  is  made  with  a  tape  measure  by  taking 
the  circumference  of  both  thighs  and  both  calves  at  the  same  level  on 
each  side.  The  level  at  which  the  circumference  is  to  be  taken  should 
be  measured  from  some  bony  point  on  both  sides,  such  as  the  anterior 
superior  spine,  the  patella,  or  the  malleoli,  to  insure  taking  the  measure- 
ment at  exactly  the  same  level.  The  conventional  places  for  such  meas- 
urements are  at  the  middle  of  the  thigh  and  the  middle  of  the  calf.  The 
absence  of  atrophy  does  not  exclude  hip  disease. 

Pain. — Tenderness  on  jarring  the  hip  is  rarely  an  early  symptom. 
Sensitiveness  on  slight  jar  of  the  hip  is  sometimes  indicated,  previous  to  the 
presence  of  conscious  pain,  by  an  instinctive  wincing  on  the  part  of  the 
patient  if  the  limb  is  jarred.  "  Night  cries  "  characteristic  of  hip  disease 
have  already  been  mentioned;  they  are  extremely  significant  in  pointing 
to  the  probable  existence  of  serious  joint  disease.  It  is  no  sign  of  the 
absence  of  hip  disease  when  one  is  able  suddenly  to  jam  the  head  of  the 
femur  into  the  acetabulum  without  causing  pain,  a  diagnostic  method 
sometimes  relied  on.  Its  violence  makes  it  unjustifiable  as  well  as  un- 
trustworthy. 

Swelling. — In  an  early  stage  of  hip  disease  there  is,  as  a  rule,  no 
swelling,  unless  the  affection  is  unusually  rapid  in  its  course;  the  glands 
in  the  groin  may,  however,  be  found  to  be  enlarged  on  palpation ;  while 
swelling  about  the  hip  is  not  uncommon  in  the  later  stage  of  hip  disease. 
Thickening  of  the  trochanter  major  is  a  diagnostic  sign  of  assistance. 
To  recapitulate  the  important  symptoms  which  establish  the  diagnosis  of 
hip  disease,  they  are:  (1)  muscular  spasm,  (2)  lameness,  (3)  attitude 
and  shortening,  (4)  atrophy,  (5)  swelling. 

Differential  Diagnosis. 

A  few  affections  are  commonly  mistaken  for  hip  disease  in  practice 
and  deserve  notice.     These  are : 

(1)  Lumbar  Pott's  disease.  (2)  Synovitis  of  the  hip.  (3)  Infantile 
paralysis.  (4)  Congenital  dislocation.  (5)  Hysterical  affections.  (6) 
Peri-articular  affections. 


232  ORTHOPEDIC   SURGERY. 

Other  affections  can  be  mistaken  for  hip  disease  only  through  ignor- 
ance of  its  proper  symptoms,  or  at  a  very  early  stage  before  the  symp- 
toms have  any  prominent  development. 

(1)  Lumbar  Pott's  disease  may  have  for  its  first  symptom  a  limp  and 
a  restriction  of  motion  in  one  leg.  This  is  due  to  the  descent  of  pus  in 
the  psoas  muscle  or  to  an  irritation  and  contraction  of  its  fibres.  As  a 
rule,  this  limited  motion  is  only  in  the  direction  of  loss  of  hyperexten- 
sion,  but  it  may  take  occasionally  the  form  of  a  general  restriction  of 
motion  and  the  joint  may  be  sensitive  to  manipulation.  The  point  to  be 
determined  is  whether  rigidity  of  the  lumbar  spine  is  present.  If  so 
Pott's  disease  is  to  be  suspected;  but  sometimes  in  hip  disease  at  a  sensi- 
tive stage,  the  tenderness  of  the  joint  is  so  great  that  on  attempted  flexion 
of  the  spine  the  erector  spinse  muscles  are  also  spasmodically  contracted 
and  lead  to  the  appearance  of  rigidity  of  the  lumbar  spine.  The  diagnosis 
may  sometimes  be  a  very  difficult  one,  and  an  opinion  must  be  withheld 
and  the  case  kept  under  observation  until  characteristic  symptoms  of  one 
affection  or  the  other  develop.  Later  in  the  history  of  lumbar  Pott's 
disease  a  psoas  abscess  will  often  descend  and  may  irritate  the  hip-joint 
on  one  or  both  sides ;  this  may  again  so  closely  simulate  hip  disease  that 
it  is  hard  to  tell  whether  the  psoas  muscle  is  causing  all  the  trouble  or 
whether  the  joint  is  really  involved. 

A  test  of  the  arc  of  abduction  of  the  hip  may  be  valuable  in  this  con- 
nection, as  this  motion  is  impaired  or  lost  at  a  comparatively  early  stage 
of  hip  disease.  It  is  an  excellent  rule  never  to  make  a  diagnosis  of 
hip  disease  without  examining  the  spine  to  see  if  Pott's  disease  is  present. 

(2)  Synovitis  of  the  hip  occurs  in  children,  but  it  presents  the  symp- 
toms of  beginning  hip  disease  and  a  diagnosis  is  not  practicable  in  the 
early  stages ;  and  the  fact  that  the  symptoms  occur  after  a  fall  must  not 
be  allowed  much  weight  as  arguing  in  favor  of  synovitis. 

It  is  distinguishable  from  true  hip  disease  only  by  its  relatively  briefer 
course.  Acute  synovitis  begins  suddenly,  generally  after  an  accident  or 
without  known  cause,  with  pain,  fever,  absolute  immobility  and  local 
swelling  of  the  hip,  the  limb  being  held  in  a  position  characteristic  of 
true  epiphyseal  ostitis.  These  symptoms  may  subside  gradually  with 
complete  recovery  of  the  joint.  In  synovitis  all  the  usual  joint  symp- 
toms, such  as  atrophy,  muscular  spasm,  etc.,  may  be  present. 

A  form  of  transient  or  ephemeral  affection  of  the  hip1  will  be  met 
in  which  all  the  signs  of  real  hip  disease  are  present  yet  complete  recovery 
occurs  in  a  few  months.  The  pathology  of  this  form  of  disease  is  as  yet 
not  investigated,  but  it  is  probable  that  in  these  cases  the  epiphysis  in 
rapidly  growing  children  is  imperfectly  ossified  and  under  slight  trauma 
becomes  congested,  a  condition  which  passes  away  under  rest. 

'Boston  Med.  and  Sur.  Journal,  cxxvii.,  161. 


HIP  DISEASE. 

In  adults,  synovitis  of  the  hip  may  come  on  clearly  after  a  fall;  there 
is  no  history  of  preceding  disability,  and  muscular  spasm  and  wasting 
are  present. 

Chronic  rheumatoid  arthritis,  morbus  coxae  senilis,  which  in  many 
cases  remains  purely  a  synovitis  without  ostitis,  begins  sometimes  idio- 
pathically  without  the  history  of  even  slight  injury.  A  diagnostic  point 
relates  always  to  the  age  at  which  the  patient  is  attacked,  it  being  prac- 
tically unknown  in  childhood,  except  in  extensive  cases  in  which  other 
joints  are  affected.  The  presence  of  rheumatoid  arthritis  may  of  course 
be  demonstrated  in  other  joints.  Acute  rheumatic  synovitis  of  the  hip  is 
occasionally  seen  even  in  children. 

(3)  At  the  stage  of  onset  of  infantile  paralysis  there  may  be  for  a 
short  time  in  rare  instances  marked  pain  and  tenderness,  with  immobility 
of  one  limb;  ordinarily  these  symptoms  are  not  accompanied  by  other 
symptoms  of  hip  disease,  but  are  accompanied  by  loss  of  power  of  the 
rest  of  the  limb  as  well  as  a  loss  of  its  normal  warmth,  rapidly  followed 
by  atrophy  in  the  whole  limb.  In  the  late  stages  of  infantile  paralysis 
there  is  no  stiffness  at  the  hip-joint,  but  we  note  abnormal  mobility  in 
all  directions  and  other  evidences  of  infantile  paralysis,  such  as  distortion 
of  the  foot  and  knee,  coldness,  atrophy,  and  marked  loss  of  power  of  cer- 
tain muscular  groups  which  make  an  error  in  diagnosis  very  unlikely. 

(4)  Congenital  Dislocation. — Congenital  dislocation  of  the  hip-joint 
need  not  be  mistaken  for  hip  disease,  as  the  clinical  history  of  the  former 
is  of  continued  limp  since  the  child  commenced  walking.  The  trochanter 
is  above  Nelaton's  line.  There  are  no  symptoms  of  muscular  stiffness  or 
limitation  of  motion  of  the  hip  in  congenital  dislocation,  in  fact  no  symp- 
toms of  hip  disease  except  the  limp  in  gait.  Patients  with  congenital 
dislocation,  however,  at  times  have  slight  attacks  of  synovitis  of  the  hip 
due  to  the  imperfect  mechanism  of  the  joint,  but  these  symptoms  subside 
after  a  short  rest. 

(5)  Hysterical  joint  affections,  as  they  are  to  be  diagnosticated  from 
organic  joint  disease,  will  be  considered  more  fully  under  the  head  of 
functional  joint  disease.  It  may  be  said  here  that  the  symptoms  of  func- 
tional and  organic  hip  disease  may  be  much  the  same. 

Coxa  vara  need  not  generally  be  confounded  with  hip  disease,  differ- 
ing as  it  does  from  the  latter  affection  in  history  and  the  symptoms  of 
marked  stiffness  of  the  joint. 

Hip  disease  is  often  diagnosticated  as  "  knee  trouble, "  so  that  it  seems 
worth  while  to  call  attention  to  the  well-known  fact  that  hip -joint  pain 
is  in  most  cases  referred  to  the  inner  side  of  the  knee.  Examination 
will  show  which  affection  is  present. 

Perinephritis  and  appendicitis  have  been  mistaken  for  hip  disease. 
Such  an  error,  however,  must  be  rare.  In  the  chronic  forms  of  these 
affections  there  may  be  slight  psoas  contractions  and  the  presence  of  iliac 


2:U  ORTHOPEDIC   SURGERY. 

abscesses.  In  these  affections  the  limitation  to  motion  of  the  thigh  at 
the  hip-joint  is  not  general  nor  does  it  affect  abduction,  but  it  is  most 
marked  in  the  direction  of  limitation  of  extension. 

In  very  rare  instances  a  partial  rupture  of  the  adductor  muscles  may 
be  mistaken  for  hip  disease.  It  can  be  distinguished  by  the  history  of 
marked  violence  and  immediate  disability,  by  the  tenderness  of  the 
adductor  muscles,  and  by  the  free  motion  of  the  hip  in  the  direction  of 
flexion  and  adduction. 

Peri-articular  disease,  which  has  not  yet  attacked  the  joint  or  the 
epiphyses  of  the  joint,  is  recognized  with  difficulty.  Under  the  head  of 
peri-articular  disease  may  be  included  inflammation  of  bursas  and  lym- 
phatic glands,  psoas  abscess,  or  psoas  muscular  spasm  from  caries  of  the 
lumbar  spine  (psoitis). 

Sarcoma  of  the  hip  may  be  mistaken  for  hip  disease  or  hip  disease  for 
sarcoma.  The  x-ray  may  give  assistance  in  the  diagnosis  and  a  piece  of 
the  growth  should  of  course  be  removed  for  examination. 

A  separation  of  the  epiphysis  of  the  femur  at  the  hip  needs  here 
scarcely  more  than  mention ;  it  is  a  rare  accident  occurring  only  before 
puberty,  and  the  symptoms  are  those  of  intercapsular  fracture  of  the 
neck  of  the  femur,  except  that  crepitus  is  not  present. 

Separation  of  the  epiphysis  may  occur,  as  has  been  said,  in  hip  disease 
and  also  in  acute  arthritis  of  the  hip.  It  would  be  recognized  by  the  fact 
that  the  trochanter  had  suddenly  become  much  higher  on  the  affected  than 
on  the  normal  side. 

Prognosis. 

Under  fairly  favorable  surroundings  the  disease  is  one  which  tends  to 
recovery  in  a  majority  of  cases  with  more  or  less  deformity.  It  is  the 
business  of  the  surgeon  to  see  that  the  chances  of  recovery  are  as  favor- 
able as  possible,  and  when  recovery  occurs  that  it  shall  result  with  the 
least  deformity  and  the  most  useful  limb  possible. 

The  prognosis  of  hip  disease  is  to  be  considered  in  two  aspects :  (a) 
the  mortality  from  the  disease ;  (b)  the  functional  results  to  be  obtained 
in  the  untreated  disease  and  under  the  different  modes  of   treatment. 

(a)  The  rate  of  the  mortality  due  to  the  disease  in  hip  disease  cannot 
be  accurately  estimated.  Ultimate  results  which  alone  are  of  value  can- 
not be  obtained  in  hospital  practice. 

Cazin1  reported  in  80  cases  of  suppurative  hip  disease  treated  at  the 
hospital  at  Berck,  in  the  course  of  five  years,  55  per  cent  were  cured ; 
12.5  per  cent  died;  25  per  cent  were  not  cured;  7.5  per  cent  were  im- 
proved when  removed.  Of  288  cases  collected  by  Gibney  there  was  a 
mortality  of  12.5  per  cent  from  exhaustion,    meningitis,    and  amyloid 

1 "  Statistique  des  Coxalgies  suppur&s,"  Bull,  de  la  Soc.  de  Chirurgie,  No.  5,  1876. 


HIP   DISEASE. 


235 


degeneration.  In  the  Alexandra  Hospital,  London,  there  were  100 
deaths  out  of  384,  a  mortality  of  26  per  cent;  of  these,  200  were  sup- 
purating cases,  and  the  death  rate  of  these  was  33.5  per  cent.  Forty- 
two  per  cent  were  reported  cured.  C.  F.  Taylor,  of  New  York,  has 
reported  94  cases  in  private  practice  with  only  3  deaths ;  of  these  94,  24 
were  suppurating.  Hueter  reports  the  mortality  of  hospital  cases  at  27 
per  cent,  and  Billroth  at  31  per  cent.  Jacobson  reported  a  mortality 
rate  of  73.2  in  63  suppurating  cases.  The  mortality  rate  from  the  disease 
alone  has  been  generally  considered  to  be  about  30  per  cent.  Shaffer  and 
Lovett  investigated  51  cases  of  cured  hip  disease  which  had  been  dis- 
charged from  the  New  York  Orthopedic  Dispensary,  at  least  four  years 
previously,  and  found  that  41  had  remained  cured.  Of  the  remaining 
10,  4  had  died  and  6  had  relapsed,  although  4  of  the  latter  had  been  ap- 
parently cured  a  second  time. ' 

Causes  of  Death. — Death  may  occur  from  (1)  the  generalization  of 
tuberculosis  in  the  form  of  phthisis,  tuberculous  meningitis,  and  general 
tuberculosis.  (2)  From  amyloid  degeneration  of  the  viscera.  (3)  From 
exhaustion.  (4)  From  intercurrent  disease.  (5)  From  septicaemia  and 
exhaustion  after  suppuration. 

In  an  analysis  of  cases  at  the  Alexandra  Hospital,  of  35  deaths  the 
causes  were  as  follows :  Meningitis,  12 ;  disease  of  the  lungs,  5 ;  amyloid 
disease,  9;  following  amputation,  3;  exhaustion,  2;  uncertain,  4. 

In  96  deaths  after  suppurative  hip  disease  at  the  Alexandra  Hospital,, 
the  causes  were  as  follows : 

Per  cent. 

Meningitis, 16.7 

Albuminuria  and  dropsy,  ....     20.8 

Phthisis, 5.2 

Phthisis  and  albuminuria,         .         .         .         .3.1 

Exhaustion,     .         .         .         .         .         .         .9.4 

Erysipelas  and  pysemia,   .          .         .         .         .3.1 

Intercurrent  disease,         .         .         .         .         .7.3 

After  operation,       ......       9.4 

Unknown,        .  .         .  .  .  .  .25.0 

In  a  series  of  11  deaths  recently  reported  in  a  series  of  150  cases  dis- 
charged from  the  Hospital  for  the  Ruptured  and  Crippled  the  causes 
were: 


Amyloid  degeneration, 
Phthisis, 

Tuberculous  meningitis, 
Cardiac  disease,    . 


11 


N.  Y.  Medical  Journal,  May  21st,  1887. 


236 


ORTHOPEDIC   SURGERY 


Of  50  deaths  known  to  have  occurred  in  778  patients  with  hip  disease 
under  treatment  at  the  New  York  Orthopedic  Dispensary  the  causes  were 
as  follows : 

Tuberculous  meningitis,       .  .  .  .  .20 


Amyloid  degeneration, 

Phthisis,    . 

Exhaustion, 

Tuberculous  peritonitis, 

Sepsis, 

Convulsions, 

Unknown, 


5 
3 
3 
1 
1 
1 
16 


(b)  Functional  Results. — Spontaneous  cure  may  result  in  hip  disease, 
but  as  a  rule  with  little  motion  and  with  marked  deformity. 

In  1878  Gibney1  reported  80  cases  which  were  cured  at  the  Hospital 
for  the  Ruptured  and  Crippled  in  New  York  by  internal  medication  and 
counter-irritation.  Abscesses  had  existed  in  48  cases,  and  in  the  other 
32  cases  there  was  present  no  abscess.  At  the  end  of  the  disease  (which 
in  33  cases  had  run  its  course  in  3  years,  in  28  cases  in  from  3  to  6  years, 
and  in  19  cases  in  from  6  to  10  years),  61  of  these  patients  could  walk  well 
and  run  without  discomfort;  12  walked  only  fairly,  requiring  a  support 
at  times ;  and  7  could  not  walk  without  crutches.  Of  these  80  cases,  12 
had,  at  least,  an  arc  of  15  degrees  motion  in  the  affected  joint,  the 
amount  of  shortening  being,  in  the  majority  of  cases,  from  1  to  3  inches. 
A  recent "  series  of  cases  from  the  same  institution,  investigated  by  Gib- 
ney, Waterman,  and  Reynolds,  is  of  interest  in  this  connection — 150  con- 
secutive cases  which  had  been  discharged  from  the  hospital  at  least  five 
years  previous  to  the  investigation.  These  cases  had  for  the  most  part 
been  under  modern  treatment,  both  mechanical  and  operative;  107  were 
cured,  25  were  still  under  treatment,  7  had  been  recommended  to  enter 
the  hospital  again  for  the  correction  of  deformity,  and  11  had  died. 

The  shortening  at  the  final  examination  in  cured  cases  was  as  follows : 
None,       .......     21  cases. 

I  inch, 


1-2  inches, 
2-3       " 
3-4       " 
6 


7 

a 

12 

a 

7 

it 

24 

U 

22 

(I 

9 

a 

4 

n 

1 

u 

07 

cases 

1  New  York  Med.  Rec,  March  2d,  1878. 
-Trans.  Am.  Orth.  Assn.,  vol.  xi.,  p.  250. 


HIP   DISEASE. 


237 


The  amount  of  motion  in  cured  cases  at  the  final  examination  was  as 
follows : 

Perfect,  .         .         .  .          .          .         .          .13 

Good, 22 

Limited,  .  .  .  .  .  .  .41 


Ankylosis, 


.     31 


Shaffer  and  Lovett '  published  a  series  of  51  cases  treated  by  the  trac- 
tion splint  at  the  New  York  Orthopedic  Dispensary  and  Hospital.  These 
patients  had  all  been  discharged  cured  from  the  institution  from  1875  to 
1882.  The  investigation  was  made  in  1886.  Only  conservative  treat- 
ment was  employed.  Of  the  41  patients  who  remained  well  (out  of  the  51 
discharged  cured)  no  one  was  incapacitated  from  doing  a  full  day's  work 
at  his  or  her  trade  or  occupation.  Only  one,  a  boy  who  had  suffered 
from  both  Pott's  disease  and  hip-joint  disease,  used  a  cane,  and  none 
used  crutches.  There  were  among  those  who  recovered,  printers,  gla- 
ziers, machinists,  errand-boys,  shop-girls,  dressmakers,  and  many  children 
attending  the  public  schools- — all  at  their  work  and  none  with  evidences 
of  active  tuberculous  disease  or  any  serious  incapacity  arising  from  the 
condition  for  which  they  were  treated  years  before. 

The  amount  of  motion  in  these  cases  was : 


No  motion  in  joint, 

.     16 

Slight  motion,     .... 

.       6 

10°  to  45°  of  motion, 

.       7 

90°  of  motion,     .... 

.       3 

Perfectly  free  motion, 

.       3 

The  amount  of  motion  diminished  after  the  cessation  of  treatment. 

If  a  cure  with  ankylosis  takes  place,  an  important  practical  point,  as 
regards  the  use  of  the  limb  and  locomotion,  is  the  position  in  which 
ankylosis  occurs.  In  15  of  the  cases  alluded  to  in  which  there  was  little 
or  no  motion  at  the  articulation,  there  was  no  flexion  of  the  thigh.  The 
limp  in  these  cases  was  trivial.  In  other  cases  the  thigh  was  flexed  at 
an  angle  of  120°  to  135°  with  the  horizontal  plane  of  the  body.  This 
was  not  a  serious  impediment  to  locomotion  when  a  flexible  dor  so-lumbar 
spine  and  a  sound  hip-joint  on  the  opposite  side  existed,  but  in  one  case 
there  was  caries  of  the  lumbar  spine,  and  in  this  case  there  was  diffi- 
cult locomotion.  Plexion  to  135°  with  a  normal  spine  does  not  produce 
either  difficult  locomotion  or  a  bad  gait,  and  in  no  case  examined  did  the 
permanent  flexion  exceed  this  angle. 

Permanent  adduction  is  a  more  important  matter.  Of  24  cases,  it  was 
very  slight  or  absent  in  13,  in  8  it  equalled  10°  to  15°,  and  in  3  cases  it 
was  about  30°.     In  2  cases  there  was  slight  abduction  of  the  thigh,  and 

>N.  Y.  Med.  Record,  March  2d.  1878. 


238 


ORTHOPEDIC   SURGERY. 


in  one  of  these  there  was  a  condition  of  hyperexteusion  of  the  knee.  But 
even  in  this  condition  the  patient  walked  well.  In  cases  in  which  abduc- 
tion was  present  in  the  earlier  history  of  the  disease,  adduction  was  found 
in  the  late  history ;  and  adduction  is  likely  to  occur  after  the  removal  of 
the  splint,  and  to  increase  up  to  a  certain  point.  But,  as  shown  above, 
adduction  to  30°  occurred  in  only  three  cases,  and  in  only  one  of  these 
was  it  troublesome.  In  this  case  with  slight  flexion,  and  adduction  to 
30°,  a  real  shortening  of  one  inch  and  a  half  became,  for  the  practical 
purpose  of  locomotion,  a  shortening  of  four  inches. 
The  shortening  was  as  follows : 


Shortening,  in  Inches. 

Cases  without  Abscess. 

Cases  with  Abscess. 

0 

2 
1 
5 
4 
8 
5 

1   

.      1 

1 

5 

u 

3 

2 

1 

2+ 

o 

1 

6 

1 

Total . . 

25 

12 

An  investigation  was  made  by  Howard  Marsh '  of  the  results  of  the 
conservative  treatment  of  hip  disease  as  practised  at  the  Alexandra 
Hospital  which  shows  the  results  to  be  obtained  by  mechanical  treatment 
(fixation).  Of  37  cases  in  which  suppuration  had  occurred  at  the  end  of 
one  year  after  discharge — 

1  was  a  perfect  recovery. 

6  were  excellent. 
17  were  good. 

13  were  moderate. 

3  had  no  shortening. 

17  had  under  1  inch. 

12  had  between  1  and  2  inches. 
3  had  2  inches  or  over. 

1  had  perfect  movement  in  every  direction. 
10  had  free  movement. 

7  had  slight  movement. 

18  were  fixed. 

The  39  cases  which  did  not  suppurate  went  on  to  still  better  results. 
There  were — 


British  Med.  Journ.,  August  3d,  1889. 


HIP   DISEASE. 


239 


9  perfect  recoveries, 
9  excellent       " 
VI  good  " 

(.)  moderate      " 

and  the  average  amount  of  shortening  was  two-thirds  of  an  inch,  while 
50  per  cent  had  what  Mr.  Marsh  classed  as  "  free  movement."  In  all 
cases  the  treatment  pursued  was  a  bed  extension  and  Thomas  splint. 

Length  of  Time  for  Treatment.  — In  general  the  disease  does  not  pre- 
sent the  appearance  of  absolute  recovery  without  probability  of  relapse 
in  well-marked  cases  under  two  or  three  years  of  treatment  at  the  short- 
est, and  it  is  best  to  continue  protection  to  the  joint  beyond  that  time. 
The  following  table  gives  the  length  of  time  that  the  cured  cases  reported 
by  Shaffer  and  Lovett  were  under  treatment : 

Table  Showing  Length  of  Time  Under  Treatment. 


2  years 4  cases. 

2i  years 4     " 

3  years 9     " 

3$  years 6 


4  years    8  cases. 

4£  years 2 

5  years 2     " 

6  years 1  case. 


6£  years 1  case. 

7  years 1     ' 

8  years 1     ' 


It  may  be  stated  that  at  least  from  two  to  three  years  will  probably  be 
needed  in  the  treatment  of  a  case  of  hip  disease  taken  at  an  early  stage, 
while  protection  to  the  joint  will  be  advisable  for  two  or  three  years 
more. 

The  early  discontinuance  of  treatment  is  a  serious  mistake,  as  relapses 
are  likely  to  occur  when  everything  seems  quiet.  Again  and  again  it  has 
been  the  experience  of  the  writers  to  change  to  a  convalescent  splint  in 
cases  in  which  the  symptoms  had  been  thoroughly  quiescent  for  months 
and  the  change  has  been  followed  by  a  relapse  within  a  few  weeks.  In  the 
same  way  too  early  a  discontinuance  of  the  convalescent  splint  will  often 
cause  trouble.  It  is  therefore  much  safer  to  err  on  the  side  of  keeping 
on  an  apparatus  unnecessarily  long  than  to  run  what  would  seem  to  be  a 
considerable  risk  of  relapse.  Even  when  a  relapse  does  not  occur,  the  too 
early  discontinuance  of  treatment  may  lead  to  an  increase  in  the  flexion 
or  adduction  deformity. 

Muscular  fixation,  or  muscular  rigidity,  diminishes  as  the  disease  im- 
proves and  motion  returns  to  the  diseased  joint.  It  may  return  entirely 
and  the  presence  or  absence  of  abscess  does  not  affect  the  outlook  in  that 
regard,  as  shown  in  the  Orthopedic  Dispensary  series. 

The  prognosis  as  to  distortion,  however,  does  not  necessarily  imply 
permanent  distortion ;  for  at  the  present  time,  after  recovery  from  hip 
disease  (the  deformity  still  existing  with  severe  flexion  and  adduction) 
these  disfigurements  can  be  entirely  and  permanently  relieved  by  sub- 


240  ORTHOPEDIC   SURGERY. 

trochanteric  osteotomy.  In  short,  by  far  the  greater  number  of  cases  of 
this  distortion  can  be  prevented  by  ordinary  care  and  thorough  treatment. 
If  they  continue  after  the  disease  at  the  hip  is  cured,  the  deformities  can 
be  overcome  with  but  slight  risk,  by  means  of  operative  interference.  It 
is,  however,  much  more  desirable  to  correct  malposition  of  the  limb 
whenever  it  occurs  than  to  allow  it  to  become  permanent  when  its  correc- 
tion is  a  much  more  serious  matter.  The  prognosis  as  to  lameness  has 
already  been  alluded  to  in  speaking  of  the  amount  of  malposition  of  the 
limb. 

Some  shortening  will  be  present  in  a  majority  of  cases  if  the  disease 
continues  for  any  time ;  but  for  practical  use  in  locomotion  the  actual 
shortening  is  of  much  less  moment  than  the  position  of  the  limb. 

In  the  Orthopedic  Dispensary  series  the  difference  in  the  length  of  the 
legs,  measured  from  the  anterior  superior  spine  of  the  ilium  to  the  inner 
malleolus,  was,  when  any  difference  existed,  from  half  an  inch  to  two 
inches  and  a  half,  with  two  exceptions.  One  patient,  with  dislocation 
of  the  head  of  the  femur,  had  six  inches  shortening,  and  one  (without 
abscess)  had  three  inches.  Two  had  absolutely  no  shortening.  The  case 
with  six  inches  shortening  and  dislocation  ran  its  entire  course  without 
evidences  of  suppuration,  while,  on  the  other  hand,  the  patients  in  whom 
there  was  absolutely  no  shortening  each  had  abscesses. 

In  general,  the  cases  with  suppuration  showed  hardly  more  shorten- 
ing than  cases  without  abscess.  The  same  point  was  elaborated  by  Hibbs 
more  fully  in  a  series  of  one  hundred  and  six  cases  at  least  two  years 
under  treatment  at  the  same  institution.  His  conclusion  from  this  in- 
vestigation was  that  "  there  is  no  reason  to  expect  greater  shortening  in 
cases  which  have  suppuration  than  in  those  that  have  not."  ' 

Actual  shortening  due  to  arrest  of  growth  of  the  limb  is  beyond  the 
control  of  the  surgeon ;  but  shortening  from  subluxation  or  dislocation  of 
the  head  of  the  femur  or  enlargement  of  the  acetabulum  may  be  said  to 
be  due  to  a  lack  of  thoroughness  of  treatment  by  traction.  Perfect  treat- 
ment may  in  some  instances  be  impossible,  from  circumstances  beyond 
the  control  of  the  surgeon ;  but  he  should  persistently  bear  in  mind  that 
subluxation  and  distortion  can  be  prevented  by  thorough  treatment  of  the 
disease. 

Atrophy  is  never  entirely  cured,  but  in  the  calf  muscles  it  diminishes 
very  much  after  the  use  of  the  leg  is  resumed. 

The  significance  of  abscess  is  not  very  great;  it  has  been  seen  that  it 
does  not  affect  the  ultimate  amount  of  motion  in  the  joint  nor  does  it 
seriously  increase  the  shortening.  The  following  table  from  the  Ortho- 
pedic Hospital  series  will  show  that  the  presence  of  abscess  not  only  did 
not  prevent  a  cure,  but  in  two  cases  a  cure  took  place  with  perfect  motion 
at  the  joint: 

1  R.  A.  Hibbs:  N.  Y.  Med.  Journ.,  November  5th,  1898. 


HIP   DISEASE.  241 

Table    Showing    the     Influence    of    the    Presence     ok    Absence 

of  Abscess  upon  Joint-Motion. 


Condition  of  Joint  as  regards  Motion. 

One  or  More 

Alisccsscs. 

No  Abscess. 

I'otal 

No  motion  in  joint. . . 

12 
i 

5 
2 

■4 

2 
2 

ID 

Slight  motion 

6 

10 J  to  45°  of  motion 

90"  of  motion 

i 

Perfectly  free  motion 

;; 

When  abscesses  occur  in  cases  under  careful  mechanical  treatment, 
the  outlook  is  worse  than  in  suppurative  hip  disease  in  general,  because 
the  careful  treatment  prevents  the  occurrence  of  abscess  in  all  but  the 
worst  cases,  so  that  in  these  the  death  rate  is  necessarily  high.  In  a 
series  of  63  cases  of  abscess  from  the  Boston  Children's  Hospital '  the  death 
rate  was  40  per  cent.  Abscess  occurred  in  18.7  per  cent  of  574  cases  of 
hip  disease  under  out-patient  treatment  which  were  analyzed, 2  whereas  the 
earlier  Alexandra  reports  gave  70  per  cent  of  abscesses;  if,  therefore, 
abscess  appears  in  spite  of  careful  treatment  and  preventive  measures  its 
prognostic  import  is  most  unfavorable.  The  spontaneous  closure  of  sinuses 
of  long  duration  is  a  favorable  prognostic  sign. 

The  amount  of  sensitiveness  of  the  hip  and  pain  in  cases  which  are 
well  treated  should  be  slight,  though  nocturnal  cries  may  persist  for  a 
while  in  the  early  stages.  The  re-occurrence  of  night  cries  late  in  the 
disease,  or  of  acute  sensitiveness  of  the  joint,  is  most  often  a  sign  of 
inadequate  treatment  or  of  trouble  coming  in  the  joint;  most  frequently 
it  precedes  the  occurrence  of  abscess. 

Under  conservative  treatment  carried  out  for  a  sufficient  time  one  may 
expect  a  good  functional  result  in  the  majority  of  cases.  In  few  diseases 
is  the  benefit  of  thorough,  skilled,  and  long-continued  treatment  more  clear, 
and  in  few  surgical  affections  can  the  surgeon  attempt  to  check  the  prog- 
ress of  disease  and  influence  recovery  with  greater  probability  of  success 
than  in  hip  disease ;  but  the  surgical  care  and  supervision  should  not  be 
limited  to  the  more  acute  stages  of  the  affection,  but  should  be  continued 
during  the  convalescent  stage  if  the  best  results  are  desired. 

The  report  of  a  few  representative  cases  may  serve  to  make  the  mat- 
ter of  prognosis  somewhat  plainer  than  it  is  possible  to  do  by  the  analysis 
of  large  groups  of  cases.  These  cases  are  taken  from  the  records  of  the 
Children's  Hospital,  and  the  patients  were  under  the  care  of  various  sur- 
geons on  service  at  the  hospital,  all,  however,  carrying  out  treatment  by 
more  or  less  efficient  traction  during  the  requisite  stages.     They  were 

•Boston  Med.  and  Surg.  Journ.,  November  21st,  1889,  p.  503. 

*Lovett:  "Pis.  of  Hip,"  p.  117. 

16 


242  ORTHOPEDIC    SURGERY. 

not  continuously,  and  in  some  cases  not  at  all,  under  the  personal  care  of 
the  writers.  They  represent  cases  in  which,  from  the  history  of  the  results, 
there  could  be  no  doubt  as  to  the  existence  of  well-marked  disease  at  the 
joint,  and  are  selected  because  of  this  fact.  They  are  all  hospital  cases 
with  treatment  at  their  homes  under  the  direction  of  the  out-patient  de- 
partment as  well  as  in  the  wards  of  the  hospital  during  the  acute  stages 
when  necessary.  They  do  not  represent  the  best  results  which  can  be 
obtained  under  more  thorough  nursing,  under  the  direction  of  a  trained 
nurse  or  an  intelligent  mother  in  exceptional  cases.  They  are  hospital 
cases  treated  in  a  routine  way.  They  are  intended  to  illustrate  the  fact 
that  in  cases  thoroughly  and  properly  treated  by  traction  subluxation  can 
be  prevented;  that  in  cases  of  the  severer  types,  if  treated  early,  some 
motion  of  the  hip-joint  can  be  preserved;  and  that  in  the  less  severe 
cases,  or  cases  in  which  prompt  and  early  treatment  was  possible,  motion 
can  be  expected. 

In  the  cases  here  reported  the  diagnosis  of  hip  disease  was  certain. 
All  cases  were  rejected  in  which  the  evidence  of  hip  disease  was  doubted, 
both  from  the  records  and  from  the  statements  of  the  examiners.  The 
record  of  motion  is  also  without  doubt  in  the  cases  where  it  is  recorded, 
as  it  was  made  with  particular  care,  and  all  cases  were  rejected  in  which 
there  was  any  doubt.  The  motion  was  tested  by  placing  the  patient  on 
the  back,  with  cne  hand  upon  the  pelvis,  the  other  manipulating  the 
thigh.  The  examination,  diagnosis,  and  subsequent  observation  were 
made  by  experienced  observers.  The  cases  had  all  been  under  observa- 
tion for  a  long  period. 

The  cases  may  be  grouped :  First,  as  those  of  hip  disease  of  a  severe 
type,  as  proved  by  the  development  of  abscess  or  the  arrest  of  growth ; 
second,  cases  without  abscess,  but  with  persistent  spasm,  limitation  of 
motion,  and  deformity,  and  a  long  period  of  pain  and  sensitiveness; 
third,  the  lighter  form  of  disease  treated  before  the  severe  symptoms  had 
been  developed.  These  cases  may  be  regarded  as  representative  ones 
seen  in  the  clinic  at  the  Children's  Hospital  where  continued  treatment 
was  carefully  carried  out. 

Cases  of  Severer  Type. 

Case  I. — Annie  F.  entered  the  out-patient  department  of  the  hospital  in  Febru- 
ary, 1888,  being  at  that  time  fifteen  years  old.  The  disease  had  been  in  progress  for 
two  years,  one  of  which  had  been  spent  in  bed.  Pain  had  been  severe  and  night 
cries  frequent.  An  abscess  had  formed,  and  the  joint  was  flexed  and  fixed.  Trac- 
tion treatment  was  begun  and  continued  for  two  years  with  traction  splint  and 
crutches.     A  protection  splint  was  worn  for  four  years  more. 

Condition,  1894.— Twenty-one  years  old ;  strong,  healthy  woman  ;  weight,  one 
hundred  and  twenty-one  pounds.  The  sinus  has  been  healed  three  years.  There  is 
motion  in  flexion  of  ten  degrees  at  the  hip-joint.  There  is  no  motion  in  other  direc- 
tions. Patient  walks  well.  There  is  a  three-inch  shortening,  but  the  trochanter  is 
not  above  Nelaton's  line.     There  is  no  deformity. 


KII"   DISEASE. 


24: 


Case  II.— Nellie  M.  entered  out-patient  department  of  the  hospital,  September, 
1884,  when  eleven  years  of  age.  The  disease  had  lasted  for  three  years.  There  bad 
been  much  pain,  and  the  patient  had  been  treated  by  high  shoe  and  crutches.  Ab- 
scesses had  been  presenfcand  a  sinus  remained.  Persistent  muscular  spasmand  pain. 
Traction  treatment  was  carried  out,  and  a  traction  splint  worn  for  three  years  and  a 


Fig.  214. 


Fig.  215. 


Figs.  214  and  215— A  Case  of  Hip  Disease  under  Ambulatory  Treatment.    Result  good.    Motion  to  right 
angle.    (Children's  Hospital  Report.) 

half  ;  after  this  a  protection  appliance  was  worn  and  is  still  worn,  although  no  symp- 
toms have  been  present  for  a  long  time. 

Condition,  1S94.—  Twenty-one  years  of  age,  strong  and  healthy.  Walks  firmly 
without  splint,  but  with  a  limp.  The  trochanter  is  below  Nedaton's  line.  There  is 
shortening  of  two  inches  from  difference  in  growth.  Motion  of  the  joint  limited  ex- 
cept in  flexion  ;  85°  of  motion  in  flexion. 

Cask  III.— George  K.  entered  the  out-patient  department  of  the  hospital  in  March, 
1887,  when  fifteen  and  a  half  years  old.  The  disease  had  existed  for  four  months. 
Traction  splint  was  applied.  The  hip  became  sensitive,  and  an  abscess  appeared  the 
following  year.  Muscular  spasm  lasted  for  two  and  a  half  years.  Traction  was  con- 
tinued for  three  years,  and  a  protection  splint  worn  four  years  longer. 

Condition,  1S94.—  Twenty-two  years  old  ;  healthy,  strong  man,  walking  with- 
out a  splint.  There  is  an  inch  and  a  half  shortening  of  the  leg,  but  no  subluxation, 
the  trochanter  being  below  Nedaton's  line.  The  position  of  the  leg  is  normal.  There 
is  no  motion. 

Case  IV.— Hattie  H.  came  to  the  out-patient  department  of  the  hospital  in 
March,  1886,  when  five  years  old.  Disease  was  of  six'  months'  duration.  The  leg 
was  flexed  to  an  angle  of  forty-five  degrees.    There  were  much  pain  and  sensitiveness. 


L>44  ORTHOPEDIC    SURGERY 

The  muscular  spasm  continued  for  nearly  two  years,  and  an  abscess  followed.  Trac- 
tion treatment  was  carried  out  for  two  years,  a  traction  splint  being  worn  a  good 
portion  of  the  lime.     A  protection  splint  was  used  for  three  years  more. 

Condition,  1894. — At  the  age  of  thirteen  the  child  is  strong  and  well.     The  tro- 


FIG.  216.  FIG.  217. 

Fics.  216  and  217.— A  Case  of  Hip  Disease  under  Ambulatory  Treatment.    Result  fair.    Motion  to  45°. 

(Children's  Hospital  Report.) 

chanter  is  below  Nelaton's  line.     There  is  a  shortening  of  half  an  inch.     Flexion  of 
ninety  degrees  is  possible.     Walks  without  a  limp.     There  is  no  deformity. 

Cases  op  the  Second  Class. 

Case  V. — Sophie  R.  entered  the  out-patient  department  of  the  hospital  in  Janu- 
ary, 1886,  when  six  years  of  age.  The  disease  had  lasted  for  nine  months  and  the  hip 
was  fixed.  There  was  pain,  and  the  spasm  lasted  for  two  years.  Treatment  by  trac- 
tion was  carried  out  for  three  years  and  by  protection  for  two  years  more.  No  abscess 
occurred. 

Condition. — January,  1893,  there  was  half  an  inch  shortening.  Flexion  was 
possible  to  a  right  angle.     Rotation  and  abduction  limited. 

Case  VII. — Robert  JI.  was  brought  to  the  hospital  in  March,  1888,  when  four 
years  old.  The  disease  had  lasted  about  two  months.  There  was  much  muscular 
spasm  at  the  hip,  with  marked  pain,  which  persisted  for  some  time,  with  swelling 
about  the  hip.  Bed  treatment  was  carried  out  for  a  month.  The  muscular  spasm 
improved  after  six  months,  but  remained  for  two  years.  Traction  treatment  was  ap- 
plied during  all  that  time,  and  a  traction  splint  worn  while  the  patient  was  up.  A 
protection  splint  was  worn  for  two  years  more. 


HIP   DISEASE. 


24-5 


Condition,  1894.— At  theage  of  ten  the  patient  walks  without  a  limp.     There  isa 
shortening  of  half  an  inch  in  the  affected  limb,  hut  no  deformity.     Motion  is  possible 

to  ninety  degrees  in  flexion  ;  rotation  is  limited. 

Case  VIII— Esther  M.  came  to  the  out-patient  department  of  the  hospital  in 
1  888,  when  eight  years  old.  Disease  had 
lasted  for  six  months.  The  hip  flexed  and 
adducted.  Pain  was  severe.  No  motion 
at  the  hip-joint  was  possible.  Pain  and 
sensitiveness  were  marked  and  bed  treat- 
ment was  necessary.  Treatment  by  trac- 
tion was  carried  out  for  three  years,  and 
protection  for  three  years  more.  Pro- 
tection splint  is  still  worn  as  a  precau- 
tion. 

Condition,  1894.  —  The  patient  is 
fourteen  years  of  age,  strong  and  well, 
and  can  walk  without  a  splint.  Forty- 
live  degrees  of  motion  is  possible  in  the 
direction  of  flexion.  There  is  an  inch 
and  a  half  of  shortening,  but  the  tro- 
chanter is  not  above  Nelaton's  line. 
There  is  no  deformity. 

Case  X. — Anastasia  H.  entered  the 
hospital  in  188(i,  when  five  years  old. 
Disease  had  been  in  progress  for  several 
months.  Night  cries  had  been  noticed 
for  three  months.  Admission  to  hospi- 
tal for  bed  treatment.  Patient  re- 
mained in  hospital  three  months. 
There  was  no  abscess.  Spasm  continued 
for  two  years.  There  were  pain  and 
persistent  adduction.  Traction  treat- 
ment carried  out  for  two  years  and  a 
half;  protection  for  a  year  and  a  half 
longer. 

Condition,  1S94-  —  Thirteen  years 
old  ;  girl  is  strong  and  well,  walks  with- 
out a  splint,  and  with  no  perceptible 
hmp.     There  is  an  inch  shortening,  but 

no  deformity.     Motion  of  ninety  degrees  possible,  but  limitation  in  other  motions. 
(Figs.  210,  220.)     , 

Casks  Treated  at  ax  Early  Stage. 

Case  XII.— James  G.  entered  the  out-patient  department  of  the  hospital  in  April, 
1800,  with  a  history  of  pain  in  the  knee  at  night  for  several  weeks.  Pain  continued 
for  some  time.  Limitation  of  motion.  There  was,  however,  but  little  muscular 
spasm.  A  traction  splint  was  applied  and  worn  continuously  for  two  years.  In 
August,  1892,  a  protection  splint  was  applied  and  has  been  worn  since  that  date. 

Condition,  1894.— The  position  of  the  leg  at  present  is  normal.  There  is  no 
shortening.     Motion  beyond  ninety  degrees.     There  is  no  muscular  spasm. 

The  diagnosis  in  this  case  is  based  upon  the  pain  which  persisted,  the  limitation 
of  motion,  and  the  length  of  time  which  the  muscular  spasm  persisted.  (Figs.  221 
and  222.) 


Fig.  218.— A  Case  of  Hip  Disease  under  Am- 
bulatory Treatment.  Result  bad.  No  motion,  dis- 
charging sinuses,  shortening  and  atrophy.  (Chil- 
dren's Hospital  Report.) 


246  ORTHOPEDIC    SURGERY. 

1   vse  XIII. — Eva  C.     T]rj  patient  entered  the  out-patient  department  of  the 
hospital  November.  1891.     There  was  severe  pain,  with  night  cries,  muscular  spasm, 


Fig.  219.  FiG.  220. 

FlGS.  :'19  and  220.— Patient,  Thirteen  Years  Old.    Traction  treatment,  two  and  one-half  years.    Protec- 
tion, one  and  one-half  years.    End  result. 

and  deformity,  and  these  symptoms  had  persisted  for  several  weeks.  The  patient 
entered  the  wards  of  the  hospital  and  remained  in  bed  with  traction  treatment  for 
six  weeks.  A  traction  splint  was  worn  for  a  year  and  then  removed  by  the  parents, 
the  child  being  considered  by  them  in  perfect  health.  The  child  was  allowed  to  use 
the  leg  freely,  and  a  relapse  occurred  after  six  months,  with  pain,  night  cries,  spasm, 
and  deformity.  Traction  treatment  was  renewed  after  a  preliminary  bed  treatment 
with  fixation  and  traction. 


HIP    DISEASE. 


LM7 


Condition,  1804. — At  the  present  time,  three  years  and  a  half  after  com nce- 

ment  of  treatment,  there  are  slight  permanent  flexion  and  free  motion  of  twenty  de- 


■z  a 


5  — 


grees.     There  are  no  subluxation  and  no  short- 
ening.    Patient  still  wears  a  traction  apparatus. 
This  case  is  reported  as  indicating  a  lack 
of  perfect  result.     Treatment  was  discontinued 
by  parents  for  several  months  and  a  relapse  oc- 
curred. 
The  case  is  still  under  observation,  but  the  ultimate  result,  which  could  in  all 
probability  have  been  without  limp,  will  be  with  a  slight  limp. 


Fig.  221.— End  Result  in  Patient 
with  Hip  Disease  under  Traction  Treat- 
ment. Traction  two  and  one-halt  years. 
Trochanter  on  N61aton's  line. 


248  ORTHOPEDIC   SURGERY. 


Treatment, 


The  treatment  of  so  chronic  an  affection  as  hip  disease  necessarily 
varies  with  the  different  indications  and  may  be  likened  to  a  long  cam- 
paign in  which  -  various  expedients  will  be  needed.  No  one  method  will 
suffice,  but  the  varying  pathological  conditions — acute  destruction,  chronic 
cicatrizing  ostitis,  periarticular  inflammation,  muscular  spasm,  and  dis- 
tortion—must be  met  by  the  rational  employment  of  the  best  counteracting 
measures.  It  is  to  be  remembered  that  the  hip-joint  differs  from  the 
other  joints  in  that  it  is  surrounded  by  strong  muscles.  These,  in  case 
of  acute  inflammation  of  the  joint,  develop  a  condition  of  exaggerated 
irritability  analogous  to  the  blepharospasm  in  ulceration  of  the  cornea. 
This  condition  needs  surgical  consideration,  as  unless  checked  it  will  de- 
velop deformity  and  destruction  of  the  joint.  The  means  at  the  surgeon's 
disposal  besides  operative  measures  may  be  classed  as  means  of  fixing 
the  joint  and  protecting  it  from  injury.  These  vary  as  the  patient 
is  confined  to  bed  or  allowed  locomotion  (the  latter,  except  for  a  rel- 
atively short  period,  being  essential  to  the  establishment  of  complete 
tissue  repair  without  which  no  cure  is  complete).  The  complications 
which  are  met  are  periarticular  abscess,  deformity,  and  extensive  ne- 
crosis. 

It  is  manifest  that  in  so  formidable  an  affection  as  hip  disease  the 
most  thorough  measures  are  necessary,  especially  during  the  stage  of 
acute  inflammation. 

Clinical  experience  as  well  as  theoretical  reasoning  demonstrates  that 
it  is  impossible  thoroughly  to  protect  a  hip-joint  when  in  an  acutely  in- 
flamed condition  without  preventing  movement  at  the  joint  on  the  part 
of  the  patient,  and  counteracting  the  increased  pressure  of  the  femur 
against  the  acetabulum  due  to  exaggerated  muscular  contraction. 

As  the  employment  of  traction  in  hip  disease  is  not  universal,  nor 
when  used  always  applied  with  sufficient  thoroughness,  it  is  desirable 
that  the  exact  effect  of  traction  on  the  hip  be  studied. 

Xo  argument  will  be  needed  to  demonstrate  the  fact  that  a  certain 
amount  of  traction  can  be  applied  to  the  femur  in  hip  disease.  A  num- 
ber of  experiments  have  been  made  to  determine  the  direction  and  amount 
of  traction  force  which  is  feasible  and  which  can  be  worn  continuously. 
The  details  of  these  experiments  will  not  be  given  here,  but  it  will  be 
stated  that  the  limit  of  traction  has  been  found  to  be  the  limit  of  the  skin 
to  endure  the  strain  of  the  adhesive-plaster  pull.  This  amount  can  be 
placed  at  from  ten  to  twenty  pounds.  It  therefore  remains  to  determine 
what  is  the  effect  of  the  traction  force  of  from  six  to  twenty  pounds  upon 
a  hip-joint  affected  by  hip  disease.  To  determine  this,  observations  were 
made  by  the  writers,  first,  on  the  cadavera  of  healthy  hips ;  second,  on 


HIP   DISEASE. 


240 


the  cadavera  of  diseased  hips;  third,  on  healthy  individuals;  and  on  pa- 
tients suffering  from  hip  disease. 

1.  Normal  Joints. — -The  hip  of  a  full-term  infant  was  prepared  in 
such  a  way  that  the  skin  was  removed  so  as  to  expose  the  muscles  around 
the  hip.  It  was  found  that  under  a  slight  amount  of  traction,  distraction 
was  possible.  This  was  not  only  visible  to  the  eye,  but  it  was  also 
demonstrable  on  a  specimen  on  which  the  skin  was  removed  without  dis- 
turbing the  ligaments  or  muscles.  A 
needle  was  inserted  in  the  head  of  the 
femur  and  another  in  the  ilium  slightly 
above  the  acetabulum,  a  slight  amount 
of  force  separating  the  two  needles. 

An  adult  dissecting-room  specimen 
was  taken,  the  femur  amputated  below 
the  trochanter,  and  the  pelvis  fixed. 
The  skin  was  not  removed  and  a  trac- 
tion force  was  applied.  Needles  were 
inserted  into  the  femur  and  into  the 
ilium,  the  skin  and  muscles  being  in- 
cised in  such  a  way  that  the  traction 
force  would  not  disturb  their  relative 
position.  Traction  of  a  hundred 
pounds  was  applied,  and  it  was  found 
that  the  needles  were  separated  an 
eighth  of  an  inch.  After  the  specimen 
had  been  soaked  in  weak  alcohol  for 
some  time  distraction  of  an  eighth  of 
an  inch  was  easily  effected  by  a  pull  of 
five  pounds. 

On  a  large  amount  of  material 
placed  at  the  disposal  of  the  writers  by 
Professor  Dwight,  of  Harvard  Univer- 
sity, it  was  clearly  shown  that  trac- 
tion distracted  in  all  cases  of  femora 
in  children  dissected    or    undissected, 

and  in  all  specimens  of  infants,  and  that  the  checks  to  distraction  in 
adult  cadavera  lay  in  the  resistance,  first,  of  the  capsular  ligament, 
especially  of  the  anterior  bands  of  the  ilio-femoral  ligament;  second,  in 
the  resistance  of  the  cotyloid  ligament,  and  to  a  slight  degree  in  atmos- 
pheric pressure.  In  children  the  lower  edge  of  the  acetabulum  presents 
no  resistance  to  a  traction  in  the  line  of  the  axis  of  the  body.  (Fig.  223.) 
In  adults  this  presents  a  resistance,  but  if  the  limb  is  abducted  the  re- 
sistance is  avoided.  Both  in  children  and  in  adults,  if  the  femur  is  ex- 
tended to  its  utmost  limit,  the  anterior  bands  of  the  ilio-femoral  liga- 


Fjg.  333.— Specimen  Showing   Distraction  of 
the  Hip  in  a  Child. 


250  ORTHOPEDIC   SURGERY. 

ment  lying  on  the  front  of  the  capsule  prevent  all  distraction  on  any  force 
which  it  is  feasible  to  apply.  If  the  capsule  and  cotyloid  ligaments  are 
disorganized,  distraction  is  easy. 

2.  Diseased  Joints. — In  a  specimen  of  a  case  of  hip  disease  of  six 
months'  duration,  in  which  death  took  place  from  scarlet  fever,  it  was 
found  that  distraction  was  easily  made  by  the  slightest  traction.  In  this 
specimen  the  cotyloid  ligament  was  disorganized,  but  the  strong  liga- 
mentous fibres  of  the  capsular  ligament  alone  served  as  a  check  to  separa- 
tion of  more  than  half  an  inch  on  traction.  But  within  that  limit  even 
the  weight  of  the  pendant  fragment  of  the  femur  distracted. 

3.  Measurements  upon  Living  Subjects. — Experiments  upon  living 
subjects  demonstrate  that  traction  distracts  under  certain  circumstances. 
A  number  of  experiments  have  been  made  on  the  subject  of  traction  by 
several  observers. '  Brackett  demonstrated  that  in  certain  cases  in  hip  dis- 
ease distraction  resulted  from  traction.  The  following  observations  have 
been  made  with  much  care  to  produce  further  evidence.  Measurements 
were  made  in  traction  both  in  health  and  in  disease.  The  experiments 
here  reported  were  made  at  the  Children's  Hospital,  and  the  writers  are 
indebted  to  Dr.  John  Dane  for  the  perfection  of  the  method  by  which  the 
experiments  were  carried  out. 

The  method  of  experiment  was  as  follows :  The  patient  was  placed 
upon  a  hard  table  with  the  head  against  the  wall,  and  perineal  straps 
upon  each  side  were  secured  to  the  head  of  the  table  by  stout  webbing. 
In  some  instances  shoulder  straps  of  a  similar  character  were  also  added. 
This  was  for  the  purpose  of  preventing  the  child  from  slipping  on  the 
table  as  far  as  possible.  All  measurements  were  taken  from  the  wall. 
Measurements  at  different  points  were  taken  by  different  observers.  The 
anterior  superior  spine  was  marked  with  a  hair  line  in  ink  on  both  sides, 
and  in  some  of  the  experiments  the  great  trochanter  was  marked  as  well. 
A  mark  was  also  made  at  the  site  of  the  external  malleolus.  A  tape  was 
carried  from  the  wall  touching  these  marks  on  the  side  experimented 
upon,  and  on  the  other  side  it  was  carried  to  the  anterior  superior  spine 
to  shoAv  any  tilting  of  the  pelvis  which  might  occur.  Traction  on  the 
leg  Avas  made  by  means  of  webbing  straps  fastened  to  a  lacing  which  did 
not  go  below  the  knee.  Traction,  therefore,  was  made  wholly  upon  the 
thigh.  Traction  was  made  by  means  of  a  spring  balance  fastened  to  the 
webbing  straps  below  the  foot.  In  each  experiment  traction  was  first 
made  of  ten  pounds;   then  of  twenty  pounds.     To  prevent  any   error 

1  Koenig,  Paschen,  and  Morosoff,  quoted  by  Lannelongue :  "Coxotuberculo.se," 
Paris,  1886;  Deutsch.  Zeit.  fiir  Chir.,  1873,  iii.,  256;  Bull,  et  M<§m.  cle  la  Soc.  de 
Chir.,  1886,  xii.,  81  ;  Boston  Med.  and  Surg.  Jour.,  1880,  ciii.,  65,  and  August  80th, 
1888;  Brackett:  Trans,  of  the  Am.  Orthop.  Assn.,  vol.  ii.  ;  also,  Trans  of  the  Am. 
Orthop.  Assn.,  vol.  vi.,  p.  127;  Bradford  &  Lovett:  Children's  Hospital  Report. 
is;  in. 


HIP  DISEASE.  251 

caused  by  the  slipping  of  the  skin  around  the  sole  of  the  foot,  a  plaster- 
of-Paris  bandage  or  a  stout  cotton  bandage  was  applied  from  the  toes  to 
the  knee,  and  upon  this  bandage  the  site  of  the  external  malleolus  was 
marked.  The  heel  was  made  to  slide  upon  a  glass  plate  to  avoid  friction. 
In  making  the  experiments  any  case  in  which  the  heel  left  the  plate 
during  the  traction,  was  thrown  out  as  inaccurate.  The  experiment  v/as 
made  as  follows : 

An  observer  was  detailed  to  watch  the  mark  made  over  the  anterior 
superior  spine;  another  observer  was  detailed  to  notice  the  mark  at  the 
external  malleolus ;  a  third  noted  the  anterior  superior  spine  on  the  well 
side,  and  in  some  of  the  earlier  experiments,  to  check  the  correctness  of 
the  method,  independent  observers  were  placed  either  at  the  knee  or  at 
the  great  trochanter.  In  most  instances  three  observers  were  employed, 
one  at  the  anterior  superior  spine,  one  at  the  external  malleolus  on  the 
diseased  side,  and  the  other  at  the  anterior  superior  spine  on  the  well 
side. 

The  patient  was  placed  upon  the  table  as  prepared,  and  each  observer 
read  the  position  that  the  line  marked  with  ink  upon  the  part  of  the  pa- 
tient he  was  to  watch  measured  on  the  tape.  Traction  of  ten  pounds  was 
"made.  Each  observer  noted  the  position  under  the  new  conditions,  and 
they  were  put  down  by  the  recorder.  Traction  of  twenty  pounds  was 
made,  and  each  observer  noted  the  position  of  the  line  on  the  tape. 
These  were  also  noted  by  the  recorder.  In  every  experiment,  unless 
otherwise  stated,  the  experiment  was  immediately  verified  with  the  ob- 
servers changed.  The  method  of  observation,  in  short,  was  to  measure 
the  distance  of  the  external  malleolus  from  the  wall ;  knowing  the  dis- 
tance of  the  anterior  superior  spine,  to  make  traction  upon  the  leg,  and  see 
how  much  the  external  malleolus  had  descended;  then,  noting  how  much 
the  anterior  superior  spine  had  been  pulled  down,  to  find  the  amount  of 
separation  between  the  external  malleolus  and  the  anterior  superior  spine, 
this  giving  the  amount  of  distraction  of  the  hip-joint  surfaces.  The 
method  of  these  experiments  has  been  related  in  detail  because  upon  its 
accuracy  the  value  of  these  experiments  depends. 

Various  sources  of  error  were  eliminated.  The  fact  that  traction  was 
made  upon  the  thigh  alone  eliminates  any  source  of  error  from  stretching 
of  the  knee-joint  ligaments. 

An  error  due  to  the  stretching  of  the  skin  may  be  disregarded  in  these 
observations.  The  skin  of  the  thigh  is  pulled  down,  but  the  skin  of  the 
leg  is  not  pulled  upon.  Consequently,  any  such  stretching  would  tend  to 
show  less  lengthening  than  really  occurred.  +-r 

In  these  experiments  traction  was  made  in  the  line  of  the  body,  and, 
unless  otherwise  stated,  the  amount  of  malposition  present  was  not  enough 
to  be  noted. 

As  evidence  of  accuracy  of  these  measurements  it  is  to  be  remembered : 


252 


ORTHOPEDIC   SURGERY 


1 .  At  the  time  of  the  experiment  the  observers  were  entirely  ignorant 
of  its  result. 

2.  The  error  caused  by  the  slipping  of  the  skin  tends  to  diminish  the 
amount  of  distraction  as  shown  by  these  experiments. 

3.  The  experiments  agree  with  each  other  and  with  those  of  other 
observers. 

Observations  on  Healthy  Joints. — The  first  experiment  was  of  special 
interest.  A  girl  of  seven,  with  dorso-lumbar  Pott's  disease,  had  an  ab- 
scess which  pointed  at  the  outer  side  of  the  thigh.  This  was  opened  by 
an  incision  of  three  inches,  exposing  the  trochanter.  The  hip-joint  was 
healthy.  Some  days  after  operation  the  girl  was  laid  upon  a  table,  se- 
cured in  place,  and  an  upright  was  erected  upon  the  table  with  the  needle 
pointing  at  a  marked  spot  on  the  exposed  trochanter.  Ten  pounds  of 
traction  produced  no  measurable  effect ;  traction  of  twenty  pounds  pro- 
duced distraction  of  a  quarter  of  an  iuch,  as  seen  by  the  mark  on  the 
trochanter  as  compared  with  the  fixed  point  adjacent — i.e.,  the  needle. 
If  traction  of  twenty  pounds  was  made,  the  head  of  the  trochanter  could 
be  seen  to  descend;  if  traction  was  suddenly  relaxed,  the  head  of  the 
femur  could  be  seen  to  move  upward. 

Traction-  int  Health. 


O1* 

Sex. 

Age. 

Condition. 

Traction 

in 
Pounds. 

Result 
in  Inches. 

1 

Male. 

6  years. 

Hip  disease  on  other  side. 

10 

Ya  lengthening. 

Verified    by    change    of 

Healthy  hip  examined. 

20 

34  lengthening. 

observers  on  repeated 
experiment. 

2 

Male. 

7  years. 

Hip  disease  on  other  side. 

10 

34  lengthening. 

VeriQed    by    change    of 

Healthy  hip  examined. 

20 

34  lengthening 

observers  on  repeated 
experiment. 

8 

Female 

7  years. 

Healthy    hip    examined. 
H  ip  disease  on  other  side. 

10 
20 

%  lengthening. 
%  lengthening. 

Not  verified. 

1 

Male. 

7  years. 

Healthy. 

10 
20 

Ya  shortening. 
Y%  lengthening. 

Verified  by  change  of 
observers. 

5 

Male. 

10  years. 

Healthy    hip    examined. 

10 

Y%  lengthening. 

Verified    bv   change    of 

H  ip  disease  on  other  side. 

20 

34  lengthening. 

observers. 

t! 

Male. 

12  years. 

Two    observations     on 
healthy  hip : 

10 
20 

No  change. 
No  change. 

Verified  by  change  of 
observers. 

Second  experiment . . . 

10 
20 

No  change. 
Ys  lengthening. 

Verified  by  change  of 
observers. 

' 

Male. 

16  years. 

Healthy    hip    examined. 
Hip  disease  on  other  side. 

First  experiment 

10 

20 

No  change. 
Ys  shortening. 

Verified  by  change  of 
observers. 

Second  experiment . . . 

10 
20 

No  change. 
Ys  shortening. 

Verified  four  times. 

The  fourth  experiment  is  of  interest,  as  it  was  done  upon  a  young 
and  particularly  well:developed  girl  without  any  disease.  Traction  of 
ten  pounds,  instead  of  causing  lengthening,  caused  an  eighth  of  an  inch 
shortening. 

The  seventh  experiment,  which  was  done  upon  a  young  man  sixteen 
years  old,  was  of  the  same  character.     Traction  of  ten  pounds  produced 


J  IIP    DISEASE. 


253 


no  effect,  but  traction  of  twenty  pounds  produced  an  eighth  of  an  inch 
shortening.  This  was  verified  four  times  with  all  the  observers  changed, 
and  the  result  in  each  case  was  the  same.  Tt  is  not  easy  to  explain  this 
phenomenon.  Possibly  in  these  cases  the  amount  of  traction  applied 
stimulated  the  healthy  muscles  to  contraction,  which  vitiated  the  meas- 
urement by  altering  the  axis  of  the  leg.  In  the  fourth  experiment  twenty 
pounds  altered  this  and  produced  a  half-inch  lengthening  in  a  boy  of  seven 
years  of  age.  It  seems  probable  that  in  the  seventh  experiment,  in  which 
the  boy  was  sixteen  years  old,,  a  larger  amount  of  traction  than  twenty 
pounds  would  have  produced  r>,  lengthening. 

Observations  upon  Diseased  Joints. — The  experiments  in  general  need 
no  comment,  except  that  it  is  interesting  to  note  that  in  Experiment  8  the 
child  had  never  had  traction  applied  before,  and  in  that  case  the  largest 
amount  of  distraction  occurred.  That  is  to  say,  it  seemed  as  if  in  the 
other  cases  in  which  traction  treatment  had  been  used  a  certain  amount 
of  previous  stretching  of  the  muscles  might  have  existed.  In  Experi- 
ment 12  traction  of  twenty  pounds  seemed  to  be  insufficient  to  cause  sep- 
aration of  the  joint  surfaces,  the  disease  having  persisted  some  time. 

Traction"  in  Disease. 


0>    tn 

a  - 
OS 

02 

fcfiS 

'A 

1 

M. 

5 

2 

F. 

5 

3 

M. 

4tf 

4 

F. 

6 

5 

M. 

6 

6 

M. 

7 

7 

M. 

7 

8 

F. 

8 

9 

M. 

10 

10 

M. 

10 

11 

M. 

12^ 

12 

M. 

16 

Length 
of  nisease. 


7  months — 

3  months 

1  year 

3   years ;     si 

nuses. 
2J4  years 

3  years 

3  months 

1  year 

3  years 

3  years 

3}4  years 

Indefinite 
over  a  year. 


Character  of  Disease. 


Acute 


Acute  and  sensitive . 


Quiescent ;  fifteen  degrees 
of  motion. 

Acute  ;  no  malposition  ; 
few  degrees  of  motion. 

Convalescent;  old  ab- 
scesses. 

Very  sensitive;  abscess, 
spasm.slightly  abducted. 

Acute  ;  some  motion 


Acute  and  spasm ;  not 
very  painful. 

Moderately  sensitive; 
very  little  motion. 

Not  sensitive ;  forty-five 
degrees  of  motion. 

Convalescent;  good  mo- 
tion. 

Forty-five  degrees  of  mo- 
tion. 


=  r  5 

2  ££ 


10 
20 
10 
20 
10 
20 
10 
20 
10 
20 
10 
20 
in 
20 
10 
20 

10 
20 
10 
20 
10 
20 
10 
20 


Result 
in  Inches. 


No  change. 
54  lengthening. 
J4  lengthening. 
V6  lengthening. 

No  change. 
y%  lengthening. 
Ye,  lengthening. 
54  lengthening. 
54  lengthening. 
%  lengthening. 
%  lengthening. 
%  lengthening. 
Vs  lengthening. 
M  lengthening. 
J4  lengthening. 
%  lengthening. 

No  change. 
%  lengthening. 
M  lengthening. 
%  lengthening. 
V%  lengthening. 
>4  lengthening. 

No  change. 

No  change. 


Verified. 

Not  verified  on  account 

of  pain. 
Verified  with  different 

observers. 
Not  verified. 

Verified. 

Verified. 

Verified. 

Verified.  Never  had 
traction  applied  be- 
fore. 

Verified. 

Verified. 
Verified. 
Verified. 


The  conclusions  which  can  be  drawn  from  this  table  seem  to  be  the 
following:  That  traction  of  ten  pounds  in  children  before  puberty  as 
a  rule  produces  lengthening  of  the  leg  in  hip  disease,  and  that  this 
lengthening  is  due  to  separation  of  the  joint  surfaces;  that  the  amount 
of  this  separation  varies  in  different  instances,  being  in  general  less  in 
older  children  than  in  young  ones,  and  also  varying  in  individual  cases 


254 


ORTHOPEDIC    SURGERY 


under  apparently  the  same  conditions,  perhaps  on  account  of  some  anatom- 
ical peculiarity ;  that  twenty  pounds  traction,  as  a  rule,  produces  more 
separation  than  ten  pounds. 

It  is  probable  that  in  the  later  cases  of  hip  disease,  in  which  cicatriza- 
tion of  the  capsular  tissue  may 
be  supposed  to  have  taken  place, 
distraction  is  not  so  readily  made. 
It  remains,  for  the  complete 
demonstration  of  the  proposition 
presented,  to  show  the  effect 
upon  the  diseased  joint  if  trac- 
tion is  efficiently  applied  for  a 
long  period.  This  can  be  done 
by  pathological  specimens  as 
well  as  by  clinical  facts. 

The  effects  of  traction,  when 
thoroughly  carried  out,  can  be 
seen  in  the  specimens  shown  in 
the  figures. 

The  first  is  that  of  a  boy  of 
nine,  who  was  attacked  with  hip 
disease  of  an  acute  form  six  years 
before.  He  was  treated  with 
traction  efficiently  for  a  long 
time,  first  with  recumbent  fixa- 
tion, later  with  an  ambulatory 
traction  splint  and  crutches, 
and  afterward  by  a  protection 
splint.  An  abscess  developed 
in  the  early  stages,  was  incised, 
and  it  subsequently  healed  en- 
tirely. The  boy  recovered  com- 
pletely after  a  number  of  years 
from  hip  disease,  having,  how- 
ever, a  limb  which  was  slightly 
shorter  (an  inch  and  a  half)  than 
the  other  and  with  limited  motion.  The  position  was  good,  and  the  leg 
was  thoroughly  useful  and  remained  so  two  years  after  the  discontinuance 
of  all  treatment,  the  boy  being  as  active  as  any  boy  at  this  time.  He 
Avas,  however,  subsequently  seized  with  tuberculous  meningitis,  being  of  a 
tuberculous  family,  and  died.  At  the  autopsy  complete  cure  of  the  hip 
disease  was  found,  and  the  specimen  (Fig.  224)  also  shows  that  there  has 
been  no  widening  of  the  acetabulum,  and  but  little  alteration  in  the  shape 
either  of  the  acetabulum  or  of  the  head  of  the  femur. 


Fh;.  234.— Hip-joint  from  Boy,  Nine  Years  Old. 
Hip  disease  had  existed  six  years  previously  and 
had  been  treated  by  traction.  Death  from  meningitis. 
Specimen  shows  no  widening  of  acetabulum,  and  but 
little  alteration  in  the  head  of  the  femur. 


HIT    DISEASE. 


255 


A  comparison  of  this  specimen  with  those  of  severe  hip  disease  in 
which  traction  was  not  nsed  speaks  most  emphatically  for  the  thorough 
use  of  the  method. 

The  specimen  shown  in  Fig.  22<'»  is  of  the  head  and  neck  of  the  femur 
in  which,  after  two  or  three  years  of  efficient  treatment  by  traction,  the 
reparative  process  was  not  sufficient  to  establish  a  cure;  the  patient's 
general  condition  failed,  and  excision  was  done.  It  is  to  be  noticed  that 
there  is  very  little  alteration  in  the  shape  of  the  head  of  the  excised 
femur.  This,  compared  with  the  accompanying  specimen  (Fig.  225)  of 
an  excision  in  a  patient  with  hip  disease  of  similar  severity  and  duration 


FIG.  335. 


Fig.  336. 


Fig.  235.— Specimen  from  Excision  of  Hip  when  Traction  had  not  been  Employed.    Severity  and  dura- 
tion of  disease  similar  to  that  of  case  in  Fig.  336. 

Fig.  226.—  Specimen  from  Excision  of  Hip  Treated  by  Efficient  Traction  for  Three  Years.    Operation 
done  because  of  failure  in  general  condition. 


in  which  no  traction  had  been  applied,  would  appear  fairly  to  show  the 
effect  of  traction  in  saving  the  head  of  the  femur  from  destruction. 

It  cannot  be  supposed  that  the  best  results  can  be  obtained  by  the 
application  of  inefficient  traction.  A  sufficient  amount  of  traction,  con- 
stantly applied  during  the  stage  of  muscular  spasm,  is  needed.  It  is,  of 
course,  not  the  only  therapeutic  measure  which  is  required ;  fixation  and 
protection  are  also  needed  at  the  various  stages.  If  traction  is  not 
applied  properly,  or  is  applied  at  the  wrong  time,  or  is  insufficient  in 
extent,  it  is  no  more  efficient  than  a  drug  injudiciously  or  wrongly  used 
or  administered  at  the  wrong  time.  Judgment  is  required  in  the  use  of 
this  measure  as  of  any  other,  and  a  great  deal  of  care  and  attention  to 
detail  is  necessary  to  insure  the  constant  application  of  from  eight  to  ten 
or  fifteen  pounds'  tractiou  uninterruptedly  for  two  or  three  or  six  months, 
not  only  on  the  part  of  the  surgeon,  but  on  the  part  of  the  nurses  and 


256 


ORTHOPEDIC    SURGERY. 


assistants.     It  is  owing  to  the  defect  in  this  respect  that  in  many  cases 
treatment  by  traction  is  ineffectual,  and  the  results  obtained  are  not  so 


Fig.  327.— Gas-Pipe  Frame.    (Children's  Hospital  Report.) 

satisfactory  as  desired.  This  leads  to  an  unjust  condemnation  of  the 
methods  of  treatment  by  traction  by  those  who  have  tried  this  method, 
and,  having  met  with  unsuccessful  results,  have  blamed  not  their  own 
method  of  application,  but  the  method  in  general,  which  is  as  irrational 
as  if  any  one  who  administered  a  drug  in  an  insufficient  dose  should  lay 
the  failure  to  the  drug,  when  it  is  properly  due  to  its  faulty  administra- 
tion. 

The  thorough  use  of  traction — i.e.,  to  the  point  of  distraction — re- 
quires on  the  part  of  the  surgeon  not  only  a  familiarity  with  the  mechani- 
cal details  of  apparatus  and  the  proper  application,  adaptation,  and  fitting 
of  appliances  suitable  in  each  case,  but  the  ability  to  arrange  for  such  co- 
operation and  assistance  on  the  part  of  nurses  or  attendants  as  shall  insure 
the  continuance  of  the  necessary  amount  of  traction  at  all  times.     If  this 


Fig.  228.— Lateral  Traction  in  Hip  Disease     (C.  G.  Page.) 

is  not  done  the  results  are  not  complete,  just  as  the  lack  of  asepsis  in  an 
assistant  or  nurse  may  vitiate  results  in  an  operation,  no  matter  how 
careful  the  surgeon  may  be  personally.     In  the  same  way  if,  through  the 


HII'    DISEASE. 


257 


neglect  of  a  nurse,  a  hip  which  needs  continued  traction  of  from  ten  to 
fifteen  pounds  for  protection  against  blows  from  muscular  spasm  is  left 
during  an  acute  stage  for  a  time  with  a  traction  of  two  pounds,  the  joint 
may  be  seriously  damaged. 

Unusual  care  is  required  both  in  the  management  of  cases  and  in  1 1n- 
direction of  hospital  services.  This  care,  however,  is  not  greater  than  is 
possible  if  sufficient  atten- 
tion is  given  to  the  subject 
and  the  surgical  indication 
borne  in  mind. 

It  is  therefore  claimed 
that  at  a  certain  stage  in 
hip  disease  traction  force  is 
desirable;  that  the  amount 
of  traction  should  be  in 
proportion  to  the  amount  of 
muscular  spasm,  and  contin- 
ued as  long  as  the  spasm 
persists.  It  is  also  clear 
and  demonstrable  that  an 
efficient  traction  force  dis- 
tracts, and  it  is  manifest 
that  distraction,  or  the  sep- 
aration of  one  inflamed  bone 
from  an  adjacent  inflamed 
bony  surface,  is  desirable; 
that  in  this  way  every 
chance  is  given  to  promote 
cure  and  cicatrization  of  the 
previously  inflamed  bone. 
If  an  indication  for  surgical 
treatment  is  ever  clearly 
written  i  n  pathological 
specimens,  certainly  that  of 

distraction  should  never  be  overlooked.  It  should  always  be  remembered 
that  in  treating  hip  disease  at  a  certain  stage  the  object  should  not  be 
simply  rest,  or  fixation,  or  protection  from  jar,  but  actual  distraction, 
and  that  traction  short  of  this  is  not  sufficiently  efficient. 

The  following  mistakes  in  the  application  of  traction  are  not  uncom- 
mon: 1.  The  use  of  a  weight  too  small  to  antagonize  to  any  extent  the 
muscular  spasm  at  the  hip.  2.  The  neglect  of  a  counter-extending  force, 
or  the  use  of  an  imperfect  one.  3.  Imperfect  hold  upon  the  leg  and  thigh 
so  that  the  traction  will  fall  upon  the  knee  and  not  upon  the  hip-joint. 
4.  Improper  fixation  of  the  patient's  trunk  and  limb,  allowing  motion. 
17 


Fig.  229. 


Plaster-of-Paris    Spica    Bandage.    (Fiske   Prize 
Fund  Essay.) 


258 


ORTHOPEDIC   SURGERY. 


5.  The  use  of  the  pulling  force  in  such  a  direction  that  the  force  is  not 
exerted  in  the  line  of  deformity.  The  amount  of  weight  to  be  used  va- 
ries according  to  the  case;  the  patient's  sensation  may  be  trusted  in  a 
measure.  In  cases  of  severe  spasm,  as  much  as  twenty  pounds  will  be 
found  to  be  well  borne,  while  in  light  cases  and  in  small  children  four 
or  five  pounds, may  be  sufficient. 

The  most  ready  way  of  applying  prevention  of  movement  of  the  pa- 
tient combined  with  traction  is  by  securing  the  patient  to  a  gas-pipe 
frame  and  exerting,  by  means  of  a  weight  and  pulley,  the  requisite  pull 
upon  the  limb.     Instead  of  the  weight  and  pulley  a  traction  attachment 


FIG.  230. 


Fig.  231. 


Fig.  333. 


Fig.  230.— Thomas'  Hip  Splint,  Single.     (Ridlon.) 

Fig.  331.— Diagrammatic  Outline.    Parallelism  of  body  and  leg  portions.    (Ridlon.) 

Fig.  232.— Thomas'  Hip  Splint,  Double.    (Ridlon.) 

to  the  frame  can  be  employed  with  perineal  counter-traction,  or  a  traction 
appliance  worn  in  connection  with  the  recumbent  frame.  In  this  the 
patient  can  be  carried  about  without  interference  with  treatment. 

Lateral  traction  suggested  by  Phelps  and  investigated  by  Page1  will  be 
found  of  service  in  the  acute  stage,  when  employed  in  connection  with 
fixation  and  longitudinal  traction  (Fig.  228). 

Fixation. — When  there  are  no  indications  for  the  employment  of  trac- 


1  Orth.  Trails.,  vii.,  239. 


HIP    DISEASE. 


259 


tion,  yet  it  is  desirable  to  prevent  extensive  movement  at  the  hip-joint,  the 
trunk  and  hip  can  be  secured  by  a  plaster-of -Paris  bandage  (Fig.  229). 

The  amount  of  fixation  furnished  by  a  plaster-of-Paris  bandage  can 
be  made  as  great  as  possible  by  applying  the  bandage  to  the  well  limb  as 
well  as  to  the  affected  one,  and  con- 
tinuing it  well  upward  on  to  the 
thorax ;  but  motion  in  the  lumbar 
region  is  possible  even  under 
these  circumstances,  and  no  direct 
check  is  given  to  the  increased 
intra-articular  pressure  from  mus- 
cular spasm.  Furthermore,  the 
method  is  a  clumsy  and  un- 
cleanly one.  It  will,  however, 
be  sometimes  found  of  use  in  un- 
ruly children  or  when  the  nursing 
is  imperfect  and  the  joint  is  sen- 
sitive. 

What  has  been  said  of  the 
plaster-of-Paris  spica,  even  when 
so  applied  as  to  hold  the  thorax 
and  the  other  leg,  is  true  of  metal 
and  leather  splints,  which  do  not 
so  completely  hold  the  joint  as 
that  does.  These  lack  fixative 
power  by  virtue  of  the  little  hold 
which  they  have  upon  the  pelvis, 
and  although  in  many  cases  of 
hip  disease  they  serve  a  thera- 
peutic purpose  in  acting  as  an 
incomplete  means   of  fixation,    they  cannot    be   advocated    for    general 


Fig.  333.— Thomas'  Splint  Applied. 
(Ridlon.) 


Posterior  View. 


The  Thomas  Splint. — The  Thomas  hip  splint,  invented  by  H.  O. 
Thomas,  of  Liverpool,  is  an  appliance  much  in  use  in  England.  It  is  a 
very  simple  apparatus,  easily  made,  and  having  many  points  of  useful- 
ness. It  consists  of  an  iron  bar  extending  from  the  inferior  angle  of  the 
scapula  to  a  little  above  the  ankle ;  the  upper  end  of  which  is  attached 
to  a  chest  piece  which  is  at  right  angles  to  the  upright  and  encircles  the 
chest,  fastening  in  front.  There  are  two  circlets  of  iron  which  grasp  the 
thigh  and  calf.  The  appliance  is  kept  in  place  by  a  wide  chest  band  and 
a  bandage  around  the  limb,  and  can  be  bent  to  fit  any  degree  of  flexion 
existing  in  the  diseased  leg  and  applied  to  it  in  that  position.  The 
apparatus  requires  much  skill  in  adjustment,  as  it  is  hard  to  fit  and  keep 
in  place.     The  posterior  bands  should  be  made  of  hoop  iron  and  should 


260 


ORTHOPEDIC    SURGERY 


be  so  placed  ou  the  upright  that  two-thirds  of  each  baud  should  be  to  the 
well  side  of  the  upright  and  one-third  to  the  diseased  side.  The  upright 
should  be  made  of  iron  three-quarters  of  an  inch  wide  by  three-sixteenths 

of  an  inch  thick.  The  chest 
band  should  be  one  and  one- 
quarter  inches  wide  and  the 
other  band  three-quarters  of  an 
inch.  Before  the  splint  is  ap- 
plied, in  addition  to  the  band 
for  the  buttock,  a  twist  should 
be  made  in  the  upright's  lon- 
gitudinal axis  between  the 
thigh  and  body  bands,  so  that 
the  thigh  and  leg  part  of  the 
splint  shall  lie  somewhat  nearer 
the  median  line  of  the  body  than 
the  body  part.  In  Thomas' 
hands  it  was  undoubtedly  an 
efficient  instrument,  but  an  ex- 
tended and  careful  use  of  the 
splint  by  the  writers,  in  many 
cases  under  all  sorts  of  con- 
ditions, has  led  them  to  a  pref- 
erence for  methods  of  treat- 
ment by  traction.  A  Thomas 
splint  cannot  be  said  to  furnish 
complete  fixation,  nor  does  it 
prevent  the  occurrence  of  sub- 
luxation, or  counteract  the 
spasmodic  muscular  contraction 
of  the  muscles  connecting  the 
lower  extremity  with  the  pelvis,  so  important  a  feature  in  hip  disease. 
There  are  two  points  in  the  use  of  the  splint  upon  which  Thomas  laid 
much  stress.  The  patient  must  not  go  about  while  muscular  spasm  and 
joint  irritability  are  present.  And  the  limb  must  not  be  disturbed  even 
for  purposes  of  examination  unless  absolutely  necessary  and  then  only  at 
intervals  of  weeks  or  months.  The  appliance,  however,  prevents  motion 
of  any  great  amount,  enables  the  patient  to  be  lifted  without  jarring  the 
hip,  and  prevents  and  corrects  flexion  of  the  thigh.  In  certain  acute  cases 
the  pain  may  be  increased  by  the  Thomas  splint,  from  the  fact  of  the  im- 
perfect fixation  furnished.  For  inasmuch  as  the  leg  and  thigh  are  firmly 
held  by  the  flat  rod  to  which  they  are  bandaged,  and  this  rod  extends  up 
the  trunk,  the  trunk  cannot  be  so  firmly  fixed  to  it  that  some  motion  will 
not  be  possible  at  its  upper  end,  as  the  patient  turns  in  bed  or  moves. 


Fig.  ~3-k— Thomas'    Splint   Outgrown    and  Neglected. 
Consequent  bad  result.    (Fiske  Prize  Fund  Essay. 


HIP    DISEASE. 


261 


Motion  of  the  upper  end  of  the  rod  is,  of  course,  communicatee!  to  the 
lower,  and  the  joint  may  in  this  way  be  twisted  and  jarred  by  the  long 
lever  attached  to  the  thigh. 

A  double  Thomas  splint  is  more  efficient  as  a  means  of  fixation,  but  it 
does  not  easily  permit  locomotion.  In  a  single  Thomas  splint  a  raised 
patten  is  put  under  the  shoe  of  the  well  foot  and  crutches  are  used. 
This  appliance  certainly  furnishes  a  ready  and  fairly  efficient  means  of 
treatment  of  hip  disease  in  the  acute  and  subacute  stage. 

A  substitute  for  the  Thomas  splint,  made  of  stout  iron  wire,  intro- 
duced by  Dr.  A.  T.  Cabot,  of  Boston,  will  be  found  of  use  in  the  case  of 
smaller  children.  This  is  practically  a  posterior  wire  splint  to  the  trunk 
and  affected  limb.  Made  of  stout  "  copper-washed  "  iron  wire  it  can  be 
easily  bent  to  fit  any  case,  and  is  covered  with  canton  flannel  after  the 
wire  has  been  wound  with  sheet  wadding.      A  body  swathe  holds  th^ 


Fig.  235.— Cabot's  Posterior  Wire  Splint.    (Fiske  Prize  Fund  Essay.) 

upper  part  of  the  splint  in  place  and  the  leg  is  bandaged  to  it.  For 
young  children  with  flexion  of  the  leg  it  is  an  admirable  splint,  but  it 
fails  to  fix  the  limb  perfectly. 

Wire  Cuirass. — The  gouttiere  de  Bonnet,  or  wire  cuirass,   furnishes 
excellent  fixation. '     It  is,  however,  cumbersome  and  expensive,  and  has 

1  For  a  modified  and  improved  wire  cuirass,  see  Nicaise  :  Rev.  de  Chir.,  January 
10th,  1888. 


262 


ORTHOPEDIC   SURGERY. 


the  defect  of  not  thoroughly  giving  the  benefit  which  can  be  afforded  by 
traction  in  relieving  the  increased  intra-articular  pressure,  unless  fur- 
nished with  arrangements  for  traction  and  counter-traction. 

Phelps,  of  New  York,  has  shown  a  method  of  fixation  by  means  of  a 
readily  made  fixation  appliance. ' 

Immobilization  and  Ankylosis. — Much  has  been  written  in  reference  to 
the  danger  of  ankylosis  incurred  by  the  immobilization  of  diseased  joints. 


Fig.  236.— Gouttiere  de  Bonnet. 
Prize  Fund  Essay.) 


CFiske 


Fig.  237.— Phelps1  Fixation  Appliance. 


That  fixation  of  a  healthy  joint  even  for  prolonged  periods  does  not 
cause  ankylosis  has  been  demonstrated  by  Phelps2  and  Eeyher.  The 
most  common  cause  of  ankylosis  in  diseased  joints  is  of  course  in  the 
cicatrization  of  the  inflamed  tissues.     Any  measure  which  tends  to  limit 


1  X.  Y.  Med.  Rec,  March  4th,  1889.  2N.  Y.  Med.  Jour.,  May  17th,  1890. 


HIP   DISEASP]. 


MM 


inflammation  tends  naturally  to  limit  rather  than  increase  the  ultimate 
impairment  of  motion.  The  cardinal  objections  to  fixation  as  a  mode  of 
treatment  are  that  it  cannot  be  made  complete  and  that  it  does  not  antag- 
onize the  harmful  effects  of  tho  tonic  muscular  contractions. 

Traction.- — Keflex  spasm  of  the  muscles  about  a  joint  is  constant  in 
all  inflamed  joints  surrounded  by  muscles,  and  it  is  of  especial  importance 


li 


Fig.  238.  Fig.  239.  Fig.  240. 

Figs.  238-240.— Forms  of  the  Long  Traction  Appliance.    (Fiske  Prize  Fund  Essay.) 


in  hip  disease,  from  the  strength  of  the  muscles  about  the  joint.  The 
harmful  effect  of  such  spasm  has  been  already  discussed. 

Traction  Splints.  — Traction  splints  exert  their  power  upon  the  joint 
by  virtue  of  pulling  down  the  leg  against  a  counter-point  of  pressure 
furnished  by  the  perineum.  A  number  of  appliances  have  been  de- 
vised for  the  purpose  of  traction,  the  principle  of  which  is  practically 
the  same,  viz.,  perineal  resistance  with  a  pulling  force  exerted  on  the 
limb. 

The  traction  splint  in  common  use  is  some  modification  of  the  original 
Davis  splint.  This  form  of  appliance  is  now  generally  known  as  the 
"long  traction  splint,"  as  well  as  the  "Taylor  splint"  and  the  "  Sayre 
long   splint";    and  various  modifications  of  it  are  identified   with  the 


264 


ORTHOPEDIC    SURGERY. 


names  of  the  surgeons  who  have  devised  the  alterations.     A  traction  ap- 
pliance consists  of  an  outside  steel  upright  reaching  from  the  trochanter 


Fig.   ~41. — Windlass  and  Ratchet  for  Extension 
(Fiske  Prize  Fund  Essay.) 


Fig.  243. — Traction  Splint. 


to  below  the  foot ;  at  the  upper  end  is  a  horizontal  rigid  pelvic  girdle  in 
which  the  patient  is  secured  by  one  or  two  perineal  straps ;  to  the  bottom 
of  the  shaft  is  attached  some  appliance  for  exercising  traction  upon  the 
limb,  the  latter  being  held  to  the  bottom  of  the  splint  by  means  of  adhe- 
sive plaster  gaiters,  circular  straps,  or  bandages. 

The  adjustment  of  traction  is  easily  provided  for  in  several  ways. 
One  is  by  means  of  a  sliding  rod  moving  within  a  tube,  the  extension  of 
the  splint  being  controlled  by  means  of  a  key  and  ratchet,  a  catch  secur- 
ing the  rod  when  in  the  proper  position.  Two  perineal  bands  are  better 
than  one ;  a  splint  with  one  band  only,  has  the  disadvantage  in  acute 
cases  r>f  affording  less  complete  fixation  to  the  diseased  joint  than  the 
form  with  the  pelvic  band  ;/, y.d  ':wo  perineal  strap:'. 

The  lower  end  is  furnished  with  a  broadened  piece,  bent  so  as  to  pass 
under  the  foot,  and  straps  are  attached  to  i'c  which  can  be  buckled  into 
buckles  secured  to  the  adhesive  plaster  on  the  patient's  leg. 


HIP   DISEASE. 


265 


A  cheaper  arrangement  for  traction  can  be  furnished  by  means  of  a 
small  windlass  on  the  foot  piece  of  the  splint,  turned  by  a  key  with  a 
ratchet.  Upon  this  windlass  are  two  pins,  or  a  rod  with  two  slits  in  it, 
to  which  the  traction  straps  are  attached.  By  turning  the  key  traction 
to  any  degree  may  be  exerted. 

The  upper  end  of  the  splint  terminates  in  a  horizontal  flat  band  en- 
circling about  three-fourths  of  the  pelvic  circumference  just  below-  the 
level  of  the  anterior  superior  spines ; 
it  should  reach  from  the  anterior  su- 
perior spine  of  the  well  side  around 
the  diseased  side  to  a  point  in  the  back 
•nearly  behind  the  end  of  the  anterior 
arm.  The  back  arm  should  be  slightly 
longer  than  the  front 
one.  Buckles  or  studs 
for  perineal  bands 
should  be  placed  on  this 
horizontal  band.  The 
sole  piece  should  ex- 
tend two  inches  below 
the  sole  of  the  bare 
foot.  There  should  be 
a  posterior  semicircular 
band  for  the  thigh  and 
one  for  the  calf. 

Perineal  bands  may 
be  made  of  webbing- 
covered  with  canton 
flannel  or  chamois  skin 
or  silk;  pads  made  of 
ground  cork  and  covered 
tightly  with  chamois  are 
useful.  Leather  sewed 
smoothly  around  a 
leather  strap  is  the 
cleanest    perineal    band 

of  all ;  but  in  the  hands  of  careless  persons  it  becomes  hard  with  the  con- 
stant wetting  from  urine,  and  is  liable  to  chafe. 

A  very  useful  perineal  band  was  devised  by  Brackett.  It  is  especially 
comfortable  in  adult  cases  and  in  the  larger  children,  and  offers  a  distinct 
advantage  in  this  way  over  any  perineal  band  that  the  writers  have  ever 
used.  The  posterior  bar  is  connected  by  a  strap  (Jb)  at  its  centre  to  the 
posterior  arm  of  the  brace,  thus  allowing  either  end  a  certain  amount  of 
vertical  oscillation.     The  three  buckles  are  fastened  to  a  similar  bar  (F), 


Fig.  243. 


FIG.  244. 


Fig.  243.— Windlass  and  Ratchet  Appliance  for  Extension. 
Prize  Fund  Essay.) 


(Fiske 


Fig.  244. — Long  Traction  Appliance, 
port.) 


(Children's    Hospital  He- 


266 


ORTHOPEDIC   SURGERY. 


which  has  two  straps  to  connect  it  with  the  anterior  arm,  little  or  no  mo- 
tion being  allowed.     Between  these  straps- and  the  perineum  is  a  piece  of 
leather  (G),  its  size  regulating  that  of  the  pad,  which  is  fastened  to  the 
bar  behind.     This  serves  to  trans- 
mit the  pressure  of  the  straps,  and 
also   to    keep    them    in    position, 
which  is  accomplished  by  button- 
hole slits,  through  which  the  straps 
pass.     The  position  of  the  straps 
is  as  follows :    The    outer  one  [A) 
passes  along  the  outer  border,  and 
is  secured  to  the  outer  buckle  (H). 


Fig.  245.— Bracken's  Perineal  Band. 


Fig.  246. 


-Long  Traction  Splint.    (From  the  Fiske 
Prize  Fund  Essay.) 


It  should  pass  beneath  the  tuberosity  of  the  ischium.  The  second,  or 
middle  one  posteriorly  {B),  crosses  obliquely  inward  to  the  inner  buckle, 
and  by  this  more  nearly  corresponds  to  the  direction  of  the  ramus  to 
which  it  gives  its  support.  The  third,  or  inner  (C),  crosses  the  one  just 
described,  and  is  secured  to  the  middle  buckle,  and  gives  its  special  sup- 
port in  the  space  formed  by  the  divergence  of  the  first  and  second.  By 
this  crossing,  the  inner  edge  of  the  pad  is  made  concave,  giving  better 
adaptation  to  the  parts.  By  this  arrangement  with  buckles,  the  surface 
can  be  made  to  fit  closely  all  the  parts  serving  for  support.  Felting  one- 
eighth  of  an  inch  in  thickness  may  be  used  to  cover  the  leather.  More 
than  this  should  not  be  used,  as  it  interferes  with  the  principle  of  the  pad. 
The  care  of  the  perineum  is  one  of  the  important  practical  points  in 
the  treatment  of  hip  disease  when  a  traction  splint  is  used.     The  kind  of 


HIP   DISEASE. 


267 


perineal  band  chosen  will  depend  largely  upon  the  surgeon's  personal 
preference,  and  often  the  choice  has  to  be  made  by  experimenting  with 
different  kinds.  The  perineum  should  be  kept  powdered,  audit  should 
be  bathed  in  alcohol  daily.  When  an  excoriation  appears  the  perineal 
band  should  be  covered  with  linen  which  is  well  spread  with  vaseline  or 
zinc  ointment  and  changed  often.  If  the  chafed  spot  becomes  worse,  the 
perineal  band  on  that  side  should  be  removed  and  the  other  band  en- 
trusted with  the  whole  weight,  or  the  child  should  be  put  to  bed,  the 
splint  removed,  traction  by  means  of  a  weight  and  pulley  in  bed  being 
used  for  a  short  time  until  the  perineum  is  healed.  Ordinarily,  with 
proper  care  aud  cleanliness,  the  perineum  is  able  to  bear  all  the  pressure 
needed. 

Traction  splints  were  intended  for  use  in  patients  who  are  not  con- 
fined to  bed,  but  it  will  be  found  that  traction  splints  can  be  made  to 

render  efficient  service  to  patients 
even  when  it  is  desirable  to  postpone 
ambulatory    treatment    and    confine 


FIG.  247.— Long  Traction  Splint,  with  Crutches. 
(Children's  Hospital  Report.) 


Fig.  248.— Adhesive  Plaster  for  Traction. 


the  patient  to  bed.     The  traction  furnished  by  traction  splints  will  be  found 
more  thorough  than  that  furnished  by  the  weight  and  pulley  methods. 

Traction   Strajjs. — The  methods  for  securing  a  hold  upon  the  limb, 
traction  straps,  as  they  are  termed,  are  the  same  which  are  needed  for 


268 


OKTHOl'KDK'    SURGERY 


the  traction  by  weight  and  pulley.  The  readiest  way  to  obtain  the  hold 
upon  the  limb  for  an  extending  force  is  by  means  of  adhesive  plaster 
applied  as  indicated  in  the  diagram.  It  should  be  applied  firmly  to  the 
thigh  above  the  knee.  If  applied  to  the  leg  alone,  traction  falls  upon  the 
knee,  and  may  cause  relaxation  of  the  ligaments  of  that  joint.  Efficient 
plaster  should  be  used,  of  a  kind  that  will  adhere  readily  without  being 
heated.     The  plasters  should  be  changed  every  three  or  four  weeks,  or 


Fig.  249.— Plaster  Traction  Applied. 


Fig.  250.— Modifled  Hip-splint.    ( Dane.) 


oftener  if  they  cause  irritation.  They  can  readily  be  removed,  if  the 
skin  and  plasters  be  thoroughly  moistened  with  benzin  or  ether.  If  any 
portion  of  the  limb  is  chafed  by  the  plaster,  it  may  be  protected  by  means 
of  a  cloth  covered  with  ointment  placed  over  the  part,  and  the  plaster  be 
applied  over  the  cloth  and  the  whole  limb ;  or  if  the  chafing  is  extensive, 
the  whole  limb  can  be  covered  with  zinc  ointment  and  protected  by  a 
smooth  bandage,  and  the  plaster  put  on  over  the  bandaged  limb.  This 
will  require  frequent  renewal,  but  will  answer  temporarily.  A  bandage 
applied  over  the  plaster  impedes  the  circulation,  and  increases  the  danger 
of  eczema  or  chafing.     If  a  bandage  is  applied  over  the  plaster,  and  worn 


HIP    DISEASE.  269 

for  a  few  hours  after  it  is  first  put  on,  sufficient  adhesion  of  the  plaster 
will  be  secured  if  proper  plaster  is  used.  In  certain  cases  an  obstinate 
eczema  is  occasioned  by  the  adhesive  plaster,  and  it  is  necessary  to  have 
recourse  to  some  other  means  of  extension.  Substitutes  for  plaster  are 
to  be  found,  gaiters  applied  to  the  ankle,  or  straps  above  the  knee. 
These,  however,  will  slip  if  more  than  a  slight  traction  force  be  applied 
and  are  not  as  a  rule  satisfactory.  Another  form  of  traction  strap  can  be 
made  in  the  following  way  :  cloth  is  cut  to  lit  the  thigh  and  leg  accurately  ; 
webbing  straps  and  buckles  or  lacings  are  attached  which  when  tightened 
give  a  hold  upon  the  thigh  above  the  knee.  If  straps  are  sewn  to  this 
leather  or  cloth  legging,  they  can  be  made  to  furnish  fairly  efficient  trac- 
tion; but  they  are  likely  to  slip,  and  are  inferior  to  the  simple  adhesive 
plaster  as  a  means  of  traction. 

A  means  of  traction  can  be  furnished  by  what  is  called  a  stocking  ex- 
tension. This  is  made  by  applying  to  the  limb  a  long  tight-fitting  stock- 
ing, which  should  reach  above  the  knee,  having  tapes  sewed  at  both  sides, 
which  should  be  longer  than  the  child's  limb,  and  reach  a  considerable 
distance  beyond  the  upper  part  of  the  stocking ;  a  bandage  should  then 
be  applied  to  the  leg  over  the  stocking,  and  the  tapes  reflected  down  the 
leg  outside  the  bandage,  and  a  second  bandage  applied  over  the  tapes, 
which  should  be  long  enough  to  extend  down  beyond  the  foot.  If  the 
tapes  are  fastened  to  the  traction  bar  a  pull  upon  the  leg  can  be  made. 

A  short  traction  splint  has  been  somewhat  used,  exerting  its  traction 
by  plaster  extension  upon  the  thigh  with  counter-traction  by  means  of  a 
perineal  strap.  It  was  originally  thought  that  this  appliance  would  be 
sufficient  to  meet  the  indications  in  the  lighter  cases,  the  patient  being 
allowed  motion  at  the  hip- joint,  walking  by  means  of  crutches;  but  it  has 
proved  unsatisfactory  and  therefore  cannot  be  recommended. 

Traction  and  recumbency  in  the  most  acute  cases  are  necessary  for 
a  time ;  this  can  be  furnished  by  means  of  a  bed  frame  to  which  is  added 
traction  by  means  of  a  traction  splint. 

Various  modifications  of  the  long  traction  splint  have  been  made, 
Which  aim,  as  a  rule,  at  furnishing  better  fixation  to  the  diseased  hip 
than  is  given  by  the  original  long  traction  appliance.  To  furnish  more 
unyielding  counter-traction  than  is  furnished  by  a  strap  Phelps  and  Dane 
have  employed  a  padded  ring  similar  to  that  in  the  ordinary  Thomas  knee 
splint.  A  combination  of  this  with  a  thoracic  band  has  been  used,  but 
when  a  frame  is  used  this  is  unnecessary,  and  when  this  is  not  used  the 
thoracic  band  (which  cannot,  while  respiration  is  allowed,  absolutely  fix 
the  thorax)  furnishes  an  arm  of  leverage  for  a  communication  of  the 
movements  of  the  child's  trunk  to  the  sensitive  hip-joint,  especially  if 
the  limb  is  firmly  attached  by  traction  to  the  splint. 

Recumbent  treatment  protects  the  joint  from  jar  more  thoroughly  than 
if  locomotion  is  allowed,  but  health-giving  activity  is  to  be  permitted  as 


270 


ORTHOPEDIC    SURGERY. 


soon  as  the  cicatrizing  ostitis  has  replaced  the  destructive  process  to  a 
sufficient  extent  to  allow  without  detriment  slight  motion  and  jar  inevita- 
ble even  to  a  protected  joint. 

Treatment  by  recumbency  is  preferable  to  ambulatory  treatment:  1. 
When  sensitiveness  of  the  hip  is  present  as  manifested  by  night  cries  or 


Fig.  251. 


-Convalescent   Hip-splint. 
Hospital  Report.) 


(Children's 


Fig.  252.— Convalescent  Splint.    (Children's  Hos- 
pital Report.) 


sensitiveness  on  moving  the  limb.  2.  When  deformity  is  present  to  a 
marked  degree  during  the  acute  stage.  3.  When  abscess  is  present  or 
threatened.  4.  In  double  hip  disease  until  the  stage  of  convalescence 
has  been  well  established.  5.  When  the  general  condition  of  the  child 
fails  under  ambulatory  treatment.  But  the  choice  between  treatment  by 
recumbency  and  ambulatory  measures  is  necessarily  a  matter  of  judgment 
varying  in  individual  cases. 

(c)  Protection. — Certain  methods  of  treatment  aim  at  protecting  the 
joint  by  preventing  injurious  jar  from  being  inflicted  upon  the  affected 
joint.  The  simplest  way  to  protect  a  joint  is  with  the  use  of  crutches, 
the  sound  limb  being  raised  by  means  of  a  patten  on  the  shoe  of  the 
sound  limb,  enabling  the  affected  limb  to  swing  free  of  the  floor.  The 
weight  of  the  limb  exerts  a  certain  amount  of  traction  force,  but  this 


HIP   DISEASE. 


271 


method  furnishes  insufficient  pull  in  children  and  does  not  protect  the 
limb  when  the  patient  sits,  or  prevent  careless  patients  from  stepping 
upon  the  limb,  and  cannot  be  regarded  as  reliable. ' 

The  ordinary  "traction"  splint,  as  described,  is  in  reality  a  protect- 
ing as  well  as  a  traction  splint,  as  it  is  longer  than  the  limb  and  passes 
under  the  foot,  enabling  the 
weight  to  be  borne  upon  the  splint 
instead  of  on  the  patient's  foot. 
Protection  without  traction  can 
be  furnished  by  omitting  the  slid- 
ing rod,  and  continuing  the  up- 
right rod  below  the  foot,  and 
expanding  it  at  the  bottom  as  in 
the  extension  splint,  or  by  insert- 
ing it  into  a  socket  in  the  boot. 
The  upright  of  the  splint  should 
be  long  enough  and  the  boot  so 
arranged  that  the  patient's  heel 
should  not  touch  the  sole  of  the 
boot,  though  the  ball  of  the  foot 
may  do  so.  The  greatest  jar  in 
locomotion  comes  as  the  heel 
strikes  the  ground  at  the  com- 
mencement of  the  step.  If  this 
jar  is  broken  by  the  splint,  the 
remaining  jar  to  the  hip  in  the 
step  will  be  diminished  at  the 
ankle  and  knee,  and  the  hip  suffi- 
ciently protected,  except  during 
the  acute  stages  of  the  disease. 

The  ordinary  protection  splint 
should  be  like  the  long  traction 
splint,  an  outside  steel  upright  with  a  horizontal  pelvic  band  at  a  level 
with  the  trochanter  carrying  perineal  straps.  It  should  be  slotted  below 
into  a  steel  sole  plate  screwed  to  the  bottom  of  the  sole,  and  when  the 
splint  is  in  place  and  the  perineal  band  buckled,  the  patient's  heel  should 
not  touch  the  heel  of  the  shoe,  but  hang  an  inch  or  so  above  it.  A  pro- 
tection splint  can  be  made  hinged  at  the  knee,  and,  if  properly  adjusted, 
patients  can  walk  about  readily  with  but  slight  discomfort.  In.  this 
way  reliable  protection  is  secured  during  the  long  period  of  convalescence 
necessary  for  the  thorough  recovery  of  the  affected  epiphysis.2 

1  Hutchison  :  American  Journal  of  the  Medical  Sciences,  January,  1877. 
2 " Mechanical  Treatment,  Hip-Joint  Disease,"  C.  F.  Taylor,  New  York  ;  andE. 
G.  Brackett :  Boston  Medical  and  Surgical  Journal,  October  6th,  1887. 


Fig.  253.  —  Jointed 
Convalescent  Splint  with 
Curved  Pelvic  Band. 
(Ridlon.) 


Fig.  254.  —Convales- 
cent Splint  Jointed  at 
Knee.  (Fiske  Prize 
Fund  Essay.) 


272  ORTHOPEDIC   SURGERY. 

If  proper  protection  is  neglected  and  not  continued  long  enough,  the 
jar  of  locomotion — the  whole  weight  being  thrown  upon  the  epiphysis 
previously  diseased — is  sufficient  to  prolong  the  stage  of  irritability,  to 
prevent  complete  cicatrization  and  ossification  of  the  inflamed  bone  tis- 
sue, to  promote  contraction  of  the  limb  and  distortion,  and  in  many  in- 
stances to  give  rise  to  relapses. 

An  appliance,  which  is  not  a  great  disfigurement,  and  will  not  inter- 
fere with  locomotion,  but  will  allow  walking,  and  which  can  be  worn 
without  discomfort  for  years  if  necessary,  is  of  great  use  in  the  treatment 
of  convalescent  hip  disease.  Simple  protection  without  traction  is  not  to 
lie  relied  upon  if  muscular  spasm  is  present.  If  muscular  spasm  is  pres- 
ent, protection  and  traction  should  both  be  employed. 

It  is  not  necessary  in  young  children  that  the  splint  be  jointed  at  the 
knee  in  a  protection  splint.  This  is,  however,  of  advantage  in  adults  in 
a  condition  of  what  may  be  termed  convalescence  from  hip  disease.  As 
the  patient's  condition  improves,  the  splint  can  be  shortened  and  jar 
gradually  be  allowed  to  come  upon  the  limb.  Protection  is  needed  for 
some  years  after  the  subsidence  of  active  symptoms.  The  need  for  the 
reapplication  of  protection  is  indicated  by  a  reappearance  of  stiffness  or 
increased  limping  on  removal  of  the  splint.  The  older  the  patient  and 
the  more  active  the  process  the  longer  protection  Avill  be  needed. 

Relapses. — Hip  disease  is  not  ended  when  the  acute  symptoms  have 
subsided;  a  process  which  requires  so  long  a  time  for  its  development 


Fig.  255.— Ward  Wagon  for  Acute  Hip  Disease.    (Children's  Hospital  Report.) 

requires  also  much  time  for  its  disappearance,  it  is  safer  not  to  discon- 
tinue traction  and  begin  simply  protective  treatment  as  soon  as  the  pain 
and  acute  symptoms  are  gone,  and  it  is  safer  not  to  discontinue  protective 
treatment  until  a  long  time  has  been  given  to  the  joint  in  which  to 
recover  itself. 

When  ambulatory  treatment  is  attempted,  it  is  desirable  that  both 


HIP   DISEASE.  273 

crutches  and  apparatus  be  used,  in  order  that  every  precaution  against 
jar  to  the  hip  be  taken.  As  it  becomes  clear  that  the  danger  of  motion 
or  jar  at  the  hip  has  diminished,  crutches  can  be  laid  aside,  with  the 


Fig.  256.— Ward  Chair  for  Acute  Hip  Disease.    (Children's  Hospital  Report.) 

continuance  of  traction  as  long  as  there  is  a  tendency  to  contraction  of 
the  limb  or  muscular  spasm.  Later  traction  may  be  discontinued,  but 
protection  still  maintained. 

It  is  impossible  to  lay  down  rules  as  to  the  time  of  the  continuance  of 
treatment  further  than  to  say  that  traction  and  partial  fixation  should  be 
continued  until  all  acute  symptoms  have  subsided  and  have  been  quiescent 
for  months  and  only  partial  stiffness  of  the  joint  remains,  due  to  inflam- 
matory adhesions  and  not  to  muscular  spasm,  and  that  protective  treat- 
ment should  then  be  pursued  for  two  or  three  years  at  least  and  discon- 
tinued gradually. 

The  Treatment  of  Complications. 

Abscess. — Abscesses  due  to  hip  disease  may  in  the  early  stages  be 
absorbed  in  some  cases  under  prolonged  treatment  by  recumbency ;  such 
a  method,  however,  seems  hardly  advisable  as  a  rule,  as  such  abscesses 
are  easily  accessible  for  operation  and  drainage.1 

Abscesses  may  also  be  left  to  enlarge  and  break  if  for  any  reason  this 
seems  desirable  in  any  individual  case. 

If  abscesses  are  well  localized  and  increasing  in  size,  and  burst  spon- 

1  Centralblatt  f.  Chir.,  April  2d,  1881. 
18 


274  ORTHOPEDIC   SURGERY. 

taneously,  they  often  are  thoroughly  evacuated,  leaving  a  sinus  which, 
after  discharging  for  some  time,  finally  heals.  Often,  however,  the 
abscess  is  not  completely  evacuated.  Some  residue  remains,  and,  gravi- 
tating along  the  lines  of  fascia?,  it  gives  rise  to  the  development  of  anoth- 
er abscess,,  until  several  collections  of  pus  may  be  developed  about  the 
joint. 

The  experience  of  the  writers  in  treatment  by  aspiration  and  the 
injection  of  germicidal  solutions  has  not  been  favorable  for  the  same  rea- 
sons as  those  mentioned  in  speaking  of  Pott's  disease.1 

Free  incision  under  strict  antiseptic  precautions  is  to  be  advised  in  all 
cases  in  which  operation  is  not  contraindicated  on  general  surgical  princi- 
ples; exploration  of  the  joint  cavity  should  be  made  if  the  abscess  com- 
municates freely  with  it,  and  possibly  softened  bone  may  be  scraped  out. 
The  abscess  cavity  should  be  examined  for  pockets,  wiped  out  with  dry 
gauze,  and  drained. 

Sinuses,  as  a  rule,  persist  for  some  time  after  operation.  "  Of  forty- 
three  cases  of  abscess  of  the  hip  operated  on  at  the  Children's  Hospital, 
between  1884  and  1888,  only  one  is  recorded  as  having  healed  within  six 
months,  while  about  half  of  the  sinuses  healed  within  periods  varying  from 
one  to  two  years,  the  rest  remaining  open."  2  In  sixty-three  cases  oper- 
ated at  the  Children's  Hospital  for  hip  abscess,  one  died  ten  days  after 
operation  of  tuberculous  meningitis.  No  sepsis  occurred  in  any  case. 
"  As  a  rule  the  operation  was  followed  by  a  decided  improvement  in  the 
general  condition  of  -the  patient,  and  by  an  improvement  in  the  joint 
symptoms."  3 

A  change  in  the  mortality  rate  at  the  Alexandra  Hospital  in  suppu- 
rative hip  disease  is  attributed  by  Marsh  to  the  fact  that  of  late  years 
abscesses  have  been  opened  and  drained.  Prior  to  1880,  the  mortality  in 
suppurating  cases  was  30.4  per  cent,  and  7  per  cent  in  non-suppurating 
cases,  while  in  a  series  of  614  cases  reported  by  him  more  recently  the 
mortality  was  only  6  per  cent.  * 

When  efficient  treatment  is  carried  out,  abscesses  as  a  rule  appear 
only  in  the  severer  cases,  in  which  drainage  is  of  benefit  to  the  disease. 
The  closure  of  abscess  cavities  by  suture  after  the  evacuation  of  their 
contents,  while  in  rare  instances  it  leads  to  permanent  union  by  first  inten- 
tion, is  not  to  be  advised,  as  breaking  down  generally  occurs.  It  must  be 
remembered  that  the  tuberculous  infection  is  not  confined  to  the  wall  of 
the  abscess,  but  extends  into  the  surrounding  tissues. 

Night  Cries. — This  troublesome  complication  usually  disappears 
quickly  after  the  establishment  of  thorough  treatment.  It  is  indicative 
of  an  active  condition  of  the  process  of  epiphyseal  ostitis.     In  some 

'N.  Y.  Med.  Jour.,  March  2d,  1889. 

'2  Boston  Med.  and  Surg.  Jour.,  September  18th,  1890. 

3Orth.  Trans.,  vol.  ii.,  p.  87. 


HIP    DISEASE. 


275 


instances  it  persists  for  several  weeks  even  under  treatment.  In  such 
cases  an  abscess  is  usually  developed,  and  with  the  incision  of  the 
abscess  the  sensitive  condition  disappears.  The  employment  of  phenac- 
etin,  salicylate  of  soda,  chloral,  has  appeared  to  be  of  some  efficiency  in 
diminishing  night  cries. ' 

Although  opiates,  chloral,  and  bromide  of  potassium  in  large  doses  will 
often  give  relief,  the  use  of  them  is  to  be  avoided  if  possible. 

Deformity. 

The  deformities  occurring  are  flexion,  abduction,  and  adduction. 
In  the  early  stages  of  the  disease  when  malposition  occurs  it  is  best  cor- 
rected by  putting  the  patient  to  bed  and  making  traction  in  the  line  of 
the  deformity. 

Slight  cases  of  deformity  can  be  corrected  by  the  use  of  appliances 
such  as  traction  splints,  which  allow  the  patient  to  go  about  with  the  aid 


Fig.  257.— Patient  on  Fixation  Frame  for  Correction  of  Deformity.    (Children's  Hospital  Report.) 

of  crutches ;  but  in  the  severer  cases  rest  in  bed  hastens  correction.  The 
traction  splint  naturally  antagonizes  adduction  of  the  limb  by  virtue  of 
its  pulling  the  leg  against  a  counter-point  in  the  perineum  which  tends 
to  abduct  the  leg  to  which  the  splint  is  applied. 

If  the  patient  is  allowed  to  roll  about  in  bed,  or  sit  up,  or  hold  the 
limb  flexed  at  the  knee,  it  is  manifest  that  no  proper  traction  force  is 
being  used. 

The  ill  effect  of  a  pulling  force  not  in  the  line  of  the  deformity  in  the 
acute  stages  of  hip  disease  is  evident.  If  an  attempt  is  made  to  force 
the  limb  down,  and  a  pull  be  made  in  the  line  of  the  axis  of  the  body, 

1  R.  W.  Lovett :  Boston  Medical  and  Surgical  Journal,  April,  1889. 


276  ORTHOPEDIC   SURGERY. 

the  head  of  the  femur  is  crowded  upward  to  the  anterior  edge  of  the 
acetabulum  by  the  force  applied  at  the  end  of  the  lever,  viz.,  the  femur, 
the  contraction  of  the  flexor  muscles  (holdiug  the  limb  flexed)  furnishing 
the  fulcrum.  In  milder  stages  of  the  disease  this  is  not  so  important  as 
in  the  acuter  stages,  but  it  is  a  mechanical  error  in  any  stage  to  attempt 
traction  except  in  the  line  of  the  deformity.  This  error  is  ofteu  the 
occasion  of  increasing  the  pain  and  sensitiveness  in  cases  of  hip  disease. 

When  the  deformity  is  of  long  standing  and  resistant,  more  force  will 
be  required. 

Howard  Marsh  has  employed  an  excellent  method,  which  is  easily 
applied  in  cases  of  adduction,  using  the  ordinary  weight-and-pulley  trac- 
tion on  each  limb,  that  applied  to  the  adducted  limb  pulling  downward 
toward  the  foot  of  the  bed  and  that  on  the  normal  limb  pulling  upward 
toward  the  head  of  the  bed. 

In  the  correction  of  adduction  a  most  efficient  appliance  is  one  recom- 
mended by  H.  L.  Taylor.1  It  is  used  during  recumbency  and  is  particu- 
larly suited  to  the  correction  of  the  relapsed  cases  occurring  in  the  late 
stages  of  the  disease. 

Brisement  Force. — In  more  resistant  deformity,  forcible  straightening 
under  an  ansesthetic  will  be  of  use,  followed  by  fixation  with  a  plaster-of- 
Paris  bandage  unless  the  resistance  is  so  firm  as  to  endanger  fracture,  in 
which  case  the  method  of  subtrochanteric  osteotomy  is  to  be  used. 

Osteotomy.- — Tenotomy,  myotomy,  and  fasciotomy  as  a  prelude  to 
brisement  force  and  osteoclasis  have  been  superseded  by  the  operation 
of  subtrochanteric  osteotomy.  The  operation  in  common  use  was  de- 
vised by  Gant;2  in  this  the  femur  is  divided  below  the  trochanter  minor. 
The  anatomical  reasons  which  he  gave  for  this  step  were  that  the  re- 
sistance of  the  psoas  and  iliacus  muscles  was  set  free  and  that  a  return 
of  the  flexion  was  not  therefore  to  be  expected,  as  when  the  bone  was 
divided  above  the  attachment  of  these  muscles.  He  also  called  attention 
to  the  fact  that  in  operating  for  ankylosis,  after  hip  disease,  it  was  de- 
sirable, if  possible,  to  make  the  section  through  healthy  bone  and  as  far 
as  possible  from  the  original  seat  of  the  disease ;  in  this  way  diminishing 
the  liability  of  rekindling  the  old  joint  inflammation. 

The  osteotome  is  a  chisel,  which  should  possess  a  temper  about  half- 
way between  that  of  a  cold  chisel  and  a  carpenter's  cutting  tool,  so  that 
the  edge  of  it  will  not  be  turned  by  the  hardness  of  the  bone.  The  cut- 
ting edge  should  be  sharp  and  the  width  of  the  blade  about  half  an  inch. 
It  is  convenient  to  have  several  osteotomes  of  the  same  width,  but  of 
different  thicknesses,  so  that  if  one  becomes  wedged  in  the  bone  it  can  be 
withdrawn  and  a  thinner  one  substituted.  The  blade  should  be  marked 
with  a  line  every  half  or  quarter  of  an  inch  from  the  cutting  edges  that 

1  N.  Y.  Med.  Jour.,  November  19th,  1887.         2  Lancet,  December,  1872,  p.  881. 


HIP   DISEASE. 


277 


one  can  tell  how  deeply  the  osteotome  has  penetrated.  A  fair-sized  wooden 
carpenter's  mallet  answers  better  than  any  of  the  lead  or  steel  ones  found 
in  the  instrument  shops. 

In  the  performance  of  the  operation  the  patient  lies  on  the  side  with 
a  sand  pillow  between  the  legs,  and  the  skin  is  sterilized  carefully.  The 
chisel  may  be  driven  in  through  the  sound  skin  about  an  inch  or  an  inch 
and  a  half  below  the  great  trochan- 
ter, according  to  whether  one  is 
operating  upon  an  adolescent  or  an 
adult.  The  chisel  should  at  first 
be  held  with  the  blade  in  the  long 
axis  of  the  limb  and  turned  when 
it  reaches  the  bone,  until  its  edge 
is  at  right  angles  to  the  axis  of  the 
limb.  The  osteotome  should  then 
be  driven  into  the  bone  by  sharp 
blows  with  the  mallet,  turning  the 
cutting  edge  first  forward  and  then 
backward,  so  as  to  cut  obliquely 
through  the  whole  shaft.  If  the 
osteotome  becomes  wedged  it  should 
be  loosened  by  lateral  motions  and 
a  thinner  one  substituted  if  possi- 
ble. Any  attempt  at  prying  with 
the  osteotome  may  result  in  break- 
ing the  blade  and  should  be  avoid- 
ed. When  the  spongy  tissue  has 
been  traversed  by  the  blade  of  the 
chisel  it  will  come  in  contact  with 
the  opposite  wall  of  solid  outside 
bone  and  will  at  once  be  felt  to 
be  driven  with  greater  resistance. 
Then,  as  Macewen  remarks,  the 
osteotome  acts  as  a  probe  as  well 

as  a  cutting  instrument.  The  bone  should  not  be  entirely  divided,  but 
when  it  seems  evident  that  only  a  shell  is  left,  attempt  should  be  made 
to  fracture  the  femur — very  little  force  is  needed,  and  if  the  bone  does 
not  yield  easily  the  chisel  should  be  again  driven  in  still  farther — always 
loosening  it  after  each  blow  of  the  mallet,  and  directing  the  blade  in  a 
new  direction. 

The  bone  breaks  with  a  loud  snap,  and  in  most  cases  the  flexed  leg 
can  be  extended  and  the  adducted  one  brought  straight  and  no  unneces- 
sary manipulation  of  the  bone  should  be  made.  Very  little  force  is 
needed  to  correct  the  deformity,  and  if  the  leg  does  not  yield  to  gentle 


Fig.  258.— Taylor's  Adduction  Splint. 


L'TS 


ORTHOPEDIC   SURGERY. 


force  then  the  best  obtainable  position  should  be  taken  and  at  some  sub- 
sequent time  rectification  should  be  completed.  There  is  little  bleeding 
and  scarcely  any  skin  wound,  unless  it  is  necessary,  as  sometimes  hap- 
pens, to  make  a  cut  in  the  anterior  surface  of  the  upper  thigh,  to  divide 
bands  of  contracted  fascia  which  prevent  full  extension  of  the  thigh. 
The  patient  should  be  placed  on  a  bed  frame  and  a  light  traction  -weight 


Fig.  259.— Combined  Pott's  and  Hip  Disease 
with  Ankylosis  of  Hip  in  Flexion  (before  Opera- 
tion).    (Goldthwait  and  Painter.) 


Fig.  260.— Same  Case  after  Subtrochanteric  Oste- 
otomy.   (Goldthwait  and  Painter.) 


applied  or  the  limb  may  be  fixed  in  the  corrected  position  by  a  well 
padded  plaster-of-Paris  bandage  including  the  whole  trunk  and  limb. 

Confinement  to  bed  should  last  between  five  and  six  weeks.  If  ad- 
duction or  abduction  is  present  it  should  be  corrected  at  the  time  of  oper- 
ation and  the  leg  retained  in  the  corrected  position ;  and  if  it  is  desired 
to  compensate  for  bone  shortening  it  can  be  done  by  putting  up  the  short- 
ened leg  in  an  abducted  position.  There  is  no  need  of  a  cuneiform  osteot- 
omy in  these  cases,  as  the  simple  linear  cut  makes  rectification  of  the 
lateral  deformity  as  easy  as  the  correction  of  the  flexion,  but  when 
marked  deformity  exists  the  osteotome  may  be  driven  obliquely  through 
the  bone.      The  risks  attending  the  operation  are  very  slight.      Hemor- 


HIP   DISEASE. 


27'J 


rhage  is  very  rare — although  accidents  have  been  reported  from  pressure 
on  the  femoral  vessels  by  sharp  edges  of  bone.1  Marked  improvement  in 
the  general  condition  of  the  patient  often  follows  the  operation.* 

The  ultimate  functional  results  following  the  operation  are  excellent. 
Although  there  may  be  no  motion  at  the  hip-joint,  the  lumbar  vertebras 
are  usually  more  movable  than  normal.  The  operation  is  indicated  in  all 
cases  of  severe  deformity  in  which  the  dis- 
tortion interferes  seriously  with  locomo- 
tion. 

Shortening  of  the  Limb. — Simple  short- 
ening of  the  limbs  after  hip-joint  disease 
and  after  excision  occurs  in  a  certain  num- 
ber of  cases;  nothing  can  be  done  to  pre- 
vent this  arrest  of  growth.  Prevention  of 
the  development  of  the  disease  and  such 
use  of  the  limb  as  is  compatible  with  safety 
of  the  joint  (inducing  proper  circulation  in 
the  limb)  may  be  regarded  as  the  only 
means  at  our  command. 

Patients  with  much  shortening  of  the 
diseased  leg  vary  a  great  deal  in  the  relief 
afforded  by  a  high  shoe;  sometimes  they 
find  it  of  the  greatest  possible  benefit,  while 
at  other  times  it  is  a  constant  annoyance. 
The  shoe  can  be  raised  by  a  cork  sole,  or 
more  cheaply  by  an  iron  or  wooden  patten, 
or  by  an  ingenious  arrangement  in  which 
the  foot,  like  the  stump  of  an  amputated 
limb,  fits  into  the  socket  of  a  specially  con- 
structed elongated  boot,  which  conceals  the 

shortening1  FlG'  361-~ Marked  Atrophy  and  Shorts 

5*  ening.    (Fiske  Prize  Fund  Essay.) 


Double  Hip  Disease. 

In  this  distressing  affection  little  difficulty  is  met  in  thorough  fixation 
of  the  patient.  By  the  ordinary  frame  and  light  traction  in  the  early 
stages  pain  and  deformity  may  be  prevented.  After  the  stage  of  spasm 
has  passed  the  patient  can  be  carried  about  in  a  double  Thomas  splint, 
and  when  convalescence  is  established  locomotion  with  protection  splints 
and  crutches  is  possible.  A  traction  splint  on  each  leg  is  also  a  useful 
method  of  treatment.     The  chief  difficulty  in  treating  double  hip  disease 

1  Post :  Ann.  Anat.  and  Surg.,  January,  1883.  and  Eev.  de  Chir.,  December.  1881 ; 
C.  T.  Poore  :  "Osteotomy  and  Osteoclasis,"  New  York,  1884. 
'-  Goldthwait :  Orth.  Trans.,  vol.  xi  .  p.  280. 


2  so 


ORTHOPEDIC   SURGERY. 


is  in  the  prevention  of  deformity,  not  during  the  active  stage  of  the  dis- 
ease, but  after  convalescence  has  been  established. 

Deformity  will  probably  not  occur  if  patients  are  kept  recumbent  for 
a  sufficiently  long  time  to  establish  a  perfect  cure.  If,  however,  they  are 
allowed  to  walk  or  move  too  soon,  before  the  joints  are  thoroughly 
strong,  weight  must  necessarily  fall  upon  the  affected  limbs  in  walking. 
If  these  are  not  sufficiently  recovered  to  sustain  the  weight,  deformity 
will  ensue.  This  danger  may  be  avoided  by  keeping  the  patient  recum- 
bent a  sufficiently  long  time.  Even  with  very  little  motion  in  either  hip- 
joint  locomotion  is  often  possible,  although  the  gait  is  necessarily  re- 
stricted. 

Excision  of  the  Hip-Joint. 

This  method  of  treatment  is  based  upon  the  opinion  that,  when  a 
tuberculous  affection  exists,  repair  is  hastened  by  the  eradication  of  the 
diseased  portion.  Excision  is  less  to  be  advocated  at  the  hip  than  at  the 
knee  or  ankle,  for  the  reason  that  it  is  difficult  and  dangerous  to  remove 
the  acetabulum,  frequently  primarily  diseased  in  hip  disease. 

The  removal  of  the  acetabulum  has  been  recently  advocated  by  Bar- 
denheuer,  but  the  mortality  of  the  procedure  is  sufficiently  high  to  pre- 
vent its  employment  except  for  the  more  severe  cases. 

It  is  therefore  impossible  in  a  large  number  of  these  cases  entirely  to 
eradicate  the  tuberculous  disease  of  the  bone  by  excision,  and  ultimate 
cure  must  depend  upon  the  overcoming  of  the  tuberculous  process  by  the 
process  of  repair.     Excision  in  the  early  cases  is  therefore  not  justified 

when  conservative  treatment  can  be  carried 
out  for  a  sufficient  time  and  with  thorough- 
ness. The  removal  of  the  head  and  neck, 
moreover,  removes  from  the  socket  one  of 
the  supports  on  which  the  trunk  rests,  and 
the  hip  is  more  mutilated  than  after  the 
cure  by  the  natural  process  of  gradual  ab- 
sorption, repair,  and  cicatrization,  which 
leaves  a  firm  though  possibly  ankylosed  hip. 
After  excision  the  hip  is  necessarily  muti- 
lated. The  operation  is  therefore  reserved 
for  the  severer  cases. 

Method  of  Operation. — Of  the  incisions  in 
common  use  the  straight  external  incision  is 
the  one  most  commonly  used,  and  the  most 
serviceable. 
There  are  various  varieties  of  the  straight  incision  which  are  advo- 
cated by  different  surgeons.     The  incision  as  described  by  Sayre  should 
begin  at  a  point  midway  between  the  anterior  superior  iliac  spine  and  the 


FIG.  262.— Straight  External  Incision 
for  Excision  of  the  Joint. 


HIP   DISEASE.  281 

great  trochanter,  the  knife  being  pushed  directly  to  the  bone.  The  cut 
should  curve  to  the  top  of  the  trochanter  and  then  downward  and  for- 
ward, the  length  of  the  incision  being  from  four  to  eight  inches.  Ollier's 
incision  is  less  curved  and  begins  four  fingers'  breadth  below  the  crest  of 
the  ilium  and  the  same  distance  behind  the  anterior  superior  spine  of  the 
ilium.  It  is  then  carried  down  to  the  top  of  the  trochanter  and  follows 
down  over  the  shaft  of  the  femur. ' 

The  tissues  should  be  incised  down  to  the  bone,  the  soft  parts  should 
be  divided,  and  the  capsule  opened.  It  is  best  to  incise  the  periosteum 
of  the  trochanter,  and  if  possible  with  a  periosteum  elevator  to  free  it 
with  its  muscular  attachments  from  the  bone.  Sometimes  the  whole  tro- 
chanter can  be  uncovered  in  this  way. 

In  using  any  of  these  incisions,  after  having  made  the  cut  down 
to  the  trochanter,  and  separated  the  periosteum  on  the  outer  side  so  far 
as  practicable,  the  next  step  is  to  separate  the  soft  tissues  from  the  bone 
on  the  inner  side,  stripping  back  the  periosteum  as  far  as  it  exists  as 
such.  In  advanced  cases  of  hip  disease,  however,  it  will  be  found  that 
all  that  it  is  practicable  to  do  is  to  clear  the  periosteum  from  the  outer 
aspect  of  the  trochanter  and  then  to  separate  the  muscular  attachments 
from  the  neck  of  the  bone,  keeping  the  knife  as  close  to  the  bone  as  pos- 
sible. Then  passing  the  finger  around  the  femur  and  adducting  the  leg 
slightly  will  raise  the  head  of  the  femur  out  of  the  acetabulum,  and  the 
capsule  can  then  be  divided  and  the  head  of  the  femur  thrown  out  into 
sight  and  sawed  off,  or  the  section  can  be  made  by  a  small  saw  or  osteo- 
tome before  dislocating  the  bone  if  the  finger  is  kept  inside  of  the  neck 
of  the  femur  as  a  guard.  If  the  head  of  the  bone  is  dislocated,  it  is  more 
easy  to  see  the  limit  of  diseased  bone  and  to  make  the  section  well  in  the 
healthy  tissue.  The  objection  to  dislocating  the  head  of  the  bone  before 
section  is  that  fracture  of  the  diseased  and  atrophied  shaft  of  the  femur 
may  occur  if  it  is  done  roughly,  and  also  periosteum  may  be  stripped  up 
from  the  inner  aspect  of  the  shaft  and  cause  necrosis.  When  the  head 
is  adherent,  it  should  be  curetted  or  chiselled  from  its  place. 

The  acetabulum  should  be  examined  and  any  sequestra  removed  and 
any  carious  surface  should  be  scraped  with  a  Volkmann's  spoon.  If  the 
acetabulum  is  perforated,  the  edges  should  be  chipped  off  until  the  point 
is  reached  where  the  periosteum  lining  the  pelvis  is  attached  to  the  bone. 
Bardenheuer  has  advocated  removal  of  the  acetabulum.  In  severe  cases  an 
incision  along  the  iliac  crest  is  made  and  the  muscles  are  stripped  down 
subperiosteally.  The  acetabulum  is  removed  with  a  chisel  or  chain  saw. 
In  eight  cases  he  removed  the  whole  acetabulum  and  five  recovered  while 
three  died.      Sprengel  has  done  a  similar  operation.2 

JBrit.  Med.  Jour.,  July  20th,  1889,  p.  119. 
2Deutsch.  med.  Woch.,  September  29th,  1898,  p.  186. 


282  ORTHOPEDIC   SURGERY. 

It  is  impossible  to  remove  all  of  the  tuberculous  material  in  excision  of 
the  hip;  and  this  must  necessarily  lead  to  relapses  and  imperfect  results 
in  many  cases.  The  mere  removal  of  the  head  of  the  bone  is  a  very  in- 
complete measure  for  the  eradication  of  the  disease  in  those  cases  in  which 
the  tuberculous  material  has  infiltrated  all  the  tissues  in  the  neighborhood 
of  the  joint.  In  many  cases  of  extensive  disease  it  is  not  easy  to  do  a 
subperiosteal  operation.  In  the  severer  cases  the  capsule  is  lax  and  par- 
tially destroyed,  so  that  the  finger  when  first  introduced  iu  the  wound 
finds  the  head  of  the  bone  only  loosely  in  contact  with  the  acetabulum 
and  dislocation  is  easily  accomplished.  The  bleeding  from  the  operation 
is  generally  trivial. 

Before  speaking  of  the  after-treatment  of  the  excision  wound,  it  is 
necessary  to  speak  of  other  incisions  recommended  for  excision  of  the 
hip. 

Anterior  Incision.- — -A  simple  straight  incision  may  be  made  from  just 
below  the  anterior  superior  spine  of  the  ilium  and  carried  downward  and 
slightly  inward  for  three  or  four  inches.  The  upper  two-thirds  of  this 
cut  should  reach  the  femur,  but  the  lower  third  should  be  more  superficial. 
The  capsule  in  this  way  will  have  been  divided  and  the  opening  into  it 
can  be  enlarged.  Then  with  a  narrow-bladed  saw  or  osteotome  the  neck 
of  the  femur  is  divided  and  the  head  removed,  but  the  Y-ligament  should 
be  left,  as  far  as  possible,  intact.  It  is  said  that  the  anterior  incision 
heals  as  well  as  any,  and  that  there  is  no  trouble  about  drainage,  but 
drainage  of  course  is  not  so  free  during  the  recumbency,  which  neces- 
sarily follows.  Calot  advocates  a  posterior  counter 7opening  when  this 
incision  is  used.  Oilier  exposes  the  trochanter,  divides  it  transversely  on 
a  level  with  the  head  of  the  femur,  carrying  down  the  section  to  the  head 
of  the  femur.  The  two  halves  of  the  head  are  then  removed  and  the 
trochanter  is  replaced. 

The  experience  of  the  writers  leads  them  to  favor  the  posterior  inci- 
sion. 

After  the  operation  a  tube  or  a  strip  of  gauze  should  be  left  in  the 
most  dependent  angle  x)f  the  wound  and  the  rest  may  be  sewed  up  if  the 
tissues  are  not  too  much  infiltrated  with  the  products  of  inflammation. 
A  heavy  antiseptic  dressing  should  then  be  applied  and  the  child  should 
be  fixed  on  a  bed  frame,  which  may  be  widened  at  the  hips  to  allow  the 
change  of  the  dressings  without  altering  the  child's  position  or  disturbing 
the  joint. 

The  hip  should  be  fixed  either  upon  a  frame  with  light  traction  or  in 
a  plasfcer-of -Paris  spica  with  the  limb  in  an  abducted  position.  As  soon 
as  it  is  practicable  the  child  should  be  allowed  to  move  about  with 
crutches,  wearing  an  appliance  to  prevent  subsequent  deformity,  a  trac- 
tion splint,  or  a  Thomas  hip  splint. 

The  mortality  immediately  after  the  operation  is  small  (7  per  cent), 


(  ;is<js. 

Per  cent 

.     48 

25-30 

.     33 

4S.5 

.   166 

36.7 

.     36 

30.5 

.     50 

44.0 

HIP   DISEASE.  283 

provided  extensive  removal  (i.e.,  of  the  acetabulum)  is  not  attempted; 
but  the  ultimate  mortality  some  time  after  the  operation  is  greater.  In 
2,464  cases  tabulated  by  Wright  (both  before  and  after  the  introduction 
of  antisepsis)  the  mortality  was  34  per  cent.  The  mortality  of  the  oper- 
ation cannot  fairly  be  judged  by  generalizing  from  the  results  of  opera- 
tion before  the  introduction  of  antiseptic  surgery.  Leisrink's  tables  of 
operations  done  without  antiseptic  precautions  set  the  death  rate  at  63.6 
per  cent.  Culbertson  tabulated  418  cases  with  41.6  per  cent  mortality. 
Sayre's  75  cases  gave  34.7  per  cent.  These  were  all  without  antisepsis. 
Under  modern  methods  the  following  groups  of  cases  give  the  re- 
ported mortality : 

Volkmann, ' 

Korff,2 

Grosch, 3      ..... 
Alexander,  .... 

Children's  Hospital,  Boston,1 
Hospital  for    Ruptured  and   Crippled, 

New  York  (Townsend 4),     .         .     99         51.5 

In  the  last  two  series  of  cases  ultimate  results  were  reported. 

An  analysis  of  100  cases  of  excision  of  the  hip  by  Mr.  Wright,  oper- 
ated on  since  the  introduction  of  antiseptic  surgery,  gives  the  following 
results,  up  to  the  time  at  which  the  patients  were  last  seen:  17  soundly 
healed,  57  unhealed,  13  dead,  5  dying  or  going  down-hill,  2  in  a  bad 
condition,  1  might  need  amputation,  4  had  undergone  amputation,  1  re- 
cent case  doing  well.  As  this  table  includes  just  100  cases,  the  percen- 
tage results  are  apparent  at  a  glance. 

The  causes  of  death  after  excision  of  the  hip  are,  aside  from  the  small 
per  cent  caused  by  the  shock  of  the  operation,  due  to  the  same  causes  as 
in  hip  disease  not  treated  by  excision,  and  it  is  certainly  not  true,  as  has 
been  claimed,  that  excision  of  the  hip  is  a  preventive  of  systemic  infec- 
tion. That  general  tuberculosis  and  tuberculous  meningitis  supervene  in 
a  certain  proportion  of  cases  of  hip  disease  is  a  fact  well  known.  In 
the  Alexandra  Hospital,  from  1867  to  1879,  there  were  23  deaths  from 
tuberculous  meningitis  in  384  cases  of  hip  disease.  There  were  in  these, 
260  suppurating  cases  with  16  deaths  (6.15  per  cent),  and  124  cases  with 
7  deaths  (5.6  per  cent).  In  these  cases  the  treatment  was  conservative 
throughout.  The  risk,  therefore,  is  a  small  one  even  in  serious  suppura- 
tive cases  treated  conservatively.  Considering  groups  of  cases  treated  by 
excision,  Mr.  Croft  reported  45  cases  with  a  mortality  of  4.4  per  cent  from 
tuberculous  meningitis.     Konig,  speaking  from  a  very  large  experience  in 


Verhdl.  d.  Dentsch.  Ges.  f.  Chir.,  1877,  59.  -Deutsch.  Zeit.  f.  Chir.,  xxii..  149. 

3 Cent.  f.  Chir.,  1882,  p.  228.         4Orth.  Trans.,  vol.  x. 


284 


ORTHOPEDIC   SURGERY. 


excisions,  stated  that  the  hope  of  immunity  from  tuberculous  infection 
had  not  been  gained  by  resection,  even  by  antiseptic  resection.  Of  21 
hip  excisions,  47.6  per  cent  had  died  of  tuberculosis  in  four  years.  Cau- 
mont  found  no  preventive  effect  in  his  cases  of  resection.  Of  26  cases 
treated  conservatively,  one-fifth  died  of  tuberculous  disease ;  while  of  12 
cases  resected,  one-third  died  of  tuberculous  infection.  Mr.  Barker,  an 
advocate  of  excision,  in  his  lecture  at  the  Koyal  College  of  Surgeons  in 

1888  on  the  treatment  of  tuberculous 
joint  disease,  said  that  in  no  less 
than  10  per  cent  of  all  deaths  fol- 
lowing excision  "  rapid  miliary  tu- 
berculosis supervened  in  such  a  way 
as  to  suggest  strongly,  if  not  to 
prove,  that  the  surgical  interference 
was  the  cause  of  the  generalization 
of  the  disease." 

The  statistics  of  Wartmann,  based 
upon  837  resections,  show  that  at 
least  10  per  cent  of  all  the  deaths 
are  caused  by  rapid  general  miliary 
tuberculosis,  coming  on  in  such  a 
way  that  it  is  strongly  suggested 
that  the  surgical  interference  stood 
in  a  causative  relation.  This  point 
has  been  of  late  often  alluded  to, 
and  the  lesson  to  be  drawn  is  that 
in  excisions  the  work  should  be  done 
cleanly,  with  as  little  tearing  of  tis- 
sue and  opening  of  lymphatics  as 
may  be,  with  the  most  careful  and 
constant  irrigation.  It  may  be 
stated  then,  in  brief,  that  resection 
of  the  hip:joint  as  an  operation  is 
attended  by  an  immediate  fatality  of 
about  7  per  cent.  The  mortality  of 
the  disease  after  the  operation  cannot  be  estimated  as  less  than  20  to 
30  per  cent,  and  when  cases  are  followed  up  for  several  years  it  is  higher 
still. 

Functional  Results. — After  excision  of  the  hip-joint  the  mechanical 
conditions  are  not  favorable  to  the  formation  of  a  firm  joint.  After 
operation  the  head  of  the  femur  is  gone  and  part  or  all  of  the  neck.  The 
capsular  ligament  is  destroyed,  and  the  upper  end  of  the  femur  lies 
loosely  against  the  ilium — perhaps  at  the  acetabulum,  perhaps  some- 
where else,  and  out  of  this  very  uncertain  contact  a  new  joint  must  be 


Fig.  263.— Late  Excision  of  Hip.    Motion  prac 
tically  perfect,    (Same  case  as  Fig.  264.) 


HIP   DISEASE. 


285 


formed  if  there  is  to  be  one,  or  else  a  union  without  motion.  A  new- 
joint  is  established  in  successful  cases,  as  has  been  shown  by  Kuster, 
Say  re,  Israel,  Woodward,  and  others. 

In  these  cases  a  synovial  sac  may  develop,  and  the  head  of  the  bone 
is  bound  firmly  to  the  ilium  so  that  a  comparatively  useful  hip-joint  re- 
mains. Such  a  case  is  figured  in  the  frontispiece  of  Sayre's  "Orthopedic 
Surgery  "  (second  edition),  in  which  there  has  been  the  formation  of  new 


Fig.  264. — Late  Excision  of  Hip.    Motion  practically  perfect. 

cartilage  and  new  fibrous  tissue,  but  the  usefulness  of  the  limb  after 
successful  excision  is  less  than  after  recovery  under  non-operative  treat- 
ment. In  some  instances  a  limb  which  was  in  excellent  condition  im- 
mediately after  the  operation  becomes  ultimately  entirely  useless.  An 
illustration  of  this  was  reported  by  one  of  the  writers'  in  a  patient  seen 
five  years  after  excision.  Iu  Culbertson's  tables'2  the  case  is  reported  as 
follows:  "  (No.  464.) — Recovered  in  six  and  two-thirds  months ;  one-half 
inch  shortening,  almost  perfect  motion.  Last  heard  from  six  and  two- 
thirds  months."  Though  the  limb  at  the  time  of  the  patient's  reported 
condition  of  cure  was  in  a  favorable  condition,  five  years  later  the  boy 
could   only  touch  the  floor  with  the  toes  of  his  affected  limb,  and  was 

1  N.  Y.  Med.  Jour.,  April,  1879.        '2  Transactions  Am.  Med.  Assn.,  1876,  p.  142. 


i'S6 


ORTHOPEDIC   SURGERY 


unable    to    walk    without    crutch    or    cane    and    could    bear  little  or  no 

weight  on  the  affected  limb. 

It  is  difficult  to  determine  definitely  how  large  a  proportion  of  useful 

limbs  ultimately  result  in 
cases  in  which  recovery 
has  taken  place  after  ex- 
cision of  the  hip.  Elben1 
traced  out  61  cases  and 
found  that  41  could  walk 
without  any  apparatus,  15 
could  walk  ouly  by  the  aid 
of  apparatus,  and  5  could 
not  walk  at  all.  The  Clini- 
cal Society's  committee  in- 
vestigated very  carefully 
12  cases  which  were  cured. 
Two  could  stand  and  hop 
on  the  excised  limb,  4 
could  stand  firmly,  4 
were  able  to  stand  but 
not  firmly,  2  could  not 
stand. 

Sherman2  reported  64 
cases  of  excision  with  13 
deaths.  Of  6  the  condi- 
tion was  not  known  (22.4 
per  cent).  Of  32  cases 
reported  in  a  table  the 
following  was  the  condi- 
tion of  the  cases  seen  at 
least   four  years  after  op- 

Fig.  265.— Late  Excision  of  Hip.    Result  fair.    Walks  with  eration  ■ 

apparatus,  but  limps.    (Fisk  Prize  Fund  Essay.) 


Age 
at  Time  of 
Operation. 

Time  since 

Operation . 

Years. 

Shorten- 
ing. 
Inches. 

1 
Ex- 
tension.      Flexion. 
Degrees. 

Ab- 
duction. 

Progression.           Limp. 

I 

4 

7 

4 

8 

3* 

16 

6 

8 
7 
6 
5 
5 
5 
4i 

2| 

2 
1* 

1 

180 
160 
180 
180 

145 

180 

130 
90 
90 

100 

"90 

120 

30 

0 

30 

10 

'45' 

Nearly  equal.    'Bad. 
One  crutch. 
Nearly  equal.    ;  None. 
Equal.                 Medium. 

Slight. 

Crutches. 

Equal.               '  Slight. 

*  Reported  by  neighbors  to  be  able  to  walk  and  run  like  other  boys. 

JCent.  f.  Chir.,  1879,  No.  2;  Med.  Times  and  Gaz.,  November  3d,  1877. 
2Orth.  Trans.,  vol.  vi.,  p.  124. 


HIP   DISEASE. 


287 


In  a  similar  series  from  the  Hospital  for  the  Ruptured  and  Crippled 
the  following  tables  are  of  interest  in  cases  not  less  than  four  years  after 
operation : 


a5 
O 

Age 

at  Time  of 

Operation. 

Years. 

Time  from 

Operation  to 

Examination. 

Years. 

a  ^ 

'3  * 

a   • 
.2  8 

§  be 

w 

a  . 

■B'S 

3  So 

Progression. 

Limp. 

||| 

g  -  q 

1 

4 

8 

2* 

180 

130 

30 

Nearly  equal. 

Bad. 

■i\ 

1 

2 

i 

7 

2 

160 

90 

0 

Uses  one  crutch. 

:j 

4 

6 

11 

180 

90 

30 

Nearly  equal. 

None. 

7 

£ 

■1 

8 

5 

H 

180 

100 

10 

Equal. 

Medium. 

33 

2f 

6 

16 

5 

•5 

"  145 

90 

Slight, 

2£ 

6* 

Uses  crutches. 

2i 

( 

(i 

4+ 

i 

180 

120 

45 

Equal. 

Slight. 

" 

H 

*  Neighbors  report  him  to  be  in  splendid  health,  able  to  walk  and  run  like  other  boys 

Table  Showing  Shortening,  Motion,  Number  of  Sinuses  Present, 
and  Angle  of  Greatest  Extension  in  12  Cases  of  Excision. 
(From  Townsend's  Series.1) 


Date  of  Operation. 


3 

4 

5 

6 

7 

8 

9 

10 

11 

12 


June  13th,  1890 

December  5th,  1890  . 
February  10th,  1891 
April  24th,  1891  .  . 

June  2d,  1891 

September  8th.  1891 . 

April  18th,  1892 

July  1st,  1892 

October  7th,  1892  .  .  . 
December  9th,  1892  . 
January  21st,  1893 


a°  o  fi 
3  <"  i ' 


February  24th,  1893 4 


6 

5f 

5f 

6* 

5 

4f 

4i 

H 


Good. 

Fair. 

Good. 

Good. 

Fair. 

Good. 

Good. 

Good. 

Good. 

Good. 

Good. 

Poor. 


\SS 


150 
135 
180 
180 
145 
165 
155 
160 
160 
165 
150 


•2  g 


0 

0 

100 

35 

10 

0 
5 
0 
0 
0 
0 
0 


2\ 

4 

3 

3 

4 

n 

2i- 
2+ 
2f 
If 
H 

n 


Shortening  After  Excision   (Townsend's  Series). 
Shortening  noted  6  years  after  operation, 

"  «        Q      "  a  it 

«  "         Q       "  a  u 

Average,    ..... 
Shortening  noted  5  years  after  operation, 

»  »         f-j       a  a  a 

»  «         5       a  a  a 

Average,   ..... 


W.  R.  Townsend  :  Orth.  Trans 


4      inches  in 

1 

3           «        " 

1 

2-L          "         " 

1 

3.16  inches. 

4        inches  in 

1 

3           "        " 

oj_         «        « 

1 

11          «        « 

x4 

1 

2.68  inches. 

,  vol.  X. 


288 


ORTHOPEDIC   SURGERY. 


Shortening  noted  4  years  after  operation, 

.«  »        j_      a  a  u 

..  "  \    J.       "  "  " 

«  u         j_       i<  u  « 

Average,    ..... 
Shortening  noted  3  years  after  operation, 

..  K  •>        it  u  (( 

it  «  6        a  (<  it 

Average,    .  .  . 

Sinuses  exist  after  operation  for  6  years  in, 

a  u      k      a         it 

tt  a      a       u  u 

u  i.      o       tt  a 

o 

a  a      9       u  a 


■         ■  2f 

inches 

in 

1 

.  2\ 

" 

it 

1 

.  n 

« 

u 

2 

.      .  ii 

a 

11 

1 

.  1.6 

inches. 

.  H 

inches 

in 

1 

.  l" 

u 

a 

1 

3 

a 

a 

2 

.  1M 

>  inches 

2 

1 

2 

1 

2 

12 

In  a  series  of  50  cases  of  excision  of  the  hip  done  at  the  Children's 
Hospital  from  1877  to  1895  it  was  possible1  to  report  on  the  condition  of 
10,  four  years  or  more  after  operation.  The  interval  ranged  from  four 
to  fourteen  years.  One  had  his  hip  amputated  later,  a  second  was  in 
poor  general  condition,  but  with  the  exception  of  the  amputated  case  no 
one  of  the  patients  used  a  cane  or  crutch ;  one  had  6  inches  of  shortening, 
one  5,  one  4,  one  had  2  inches,  and  three  had  only  1  inch.  The  amount 
of  motion  in  flexion  in  those  of  the  10  cases  in  which  it  was  recorded  was 
as  follows:  None,  25°,  40°,  45°,  60°,  65°,  80°. 

The  indications  for  excision  can  be  stated  as  follows : 

1.  When  conservatism  is  impossible  owing  to  lack  of  facilities  for 
thorough  treatment,  and  the  affection  is  rapidly  progressive. 

2.  When  a  progressive  destructive  process  has  continued  in  the  hip- 
joint  unarrested  by  the  most  favorable  conditions. 

3.  When  the  process  is  so  acute  that  it  threatens  not  only  the  de- 
struction of  the  joints  but  endangers  life. 

4.  When  an  extensive  sequestrum  is  present. 

European  surgeons  apparently  resect  a  larger  proportion  of  cases  than 
would  be  the  case  under  the  indications  just  given. 

Vincent,  of  Lyons,  in  233  cases  of  hip  disease  treated  at  the  Charite 
Hospital  resected  52  (22.3  per  cent). 

Sasse  believes  that  conservative  measures  can  be  followed  in  75  to  80 
per  cent  of  all  cases  (leaving  from  20  to  25  per  cent  of  cases  for  excision), 
an  estimate  practically  the  same  as  Vincent's. 


Lovett :  Orth.  Trans. ,  vol.  x. 


HIP    DISEASE. 


289 


Brians,1  reviewing  forty  years'  work  at  the  Tubingen  clinic,  found  600 
cases  which  he  reduced  to  390  cases  of  authenticated  hip  disease;  and  of 
these,  69  were  resected,  making  about  18  per  cent,  a  proportion  not  far 
from  those  of  the  other  Continental  surgeons  just  mentioned.  At  the 
Children's  Hospital, 
Boston,  in  1,100  cases, 
50  were  resected,  being 
at  the  rate  of  4.5  per 
cent. 

It  must  be  borne 
in  mind  that  results 
as  to  mortality  after 
early  excisions  (before 
extensive  destruction 
in  the  bone  has  taken 
place)  are  much  more 
favorable  than  after 
late  excision,  as  has 
been  shown  in  the  fig- 
ures of  Grosch.  The 
results  of  careful  con- 
servative treatment,  if 
carried  out  for  a  long 
time,  are  superior  to 
those  after  excision  in 
a  majority  of  cases, 
and  when  conservative 
treatment  is  practica- 
ble it  should  be  pre- 
ferred. The  functional 
results  of  conservative 
treatment  so  far  as 
formulated   m    groups 

of  cases  treated  by  this  method  have  been  discussed  under  the  head- 
ing of  prognosis  in  this  chapter.  In  large  hospitals  or  among  a  poor 
and  unintelligent  class,  conservative  treatment  is  sometimes  imprac- 
ticable, and  in  such  cases  excision  is  resorted  to  earlier  than  would 
otherwise  be  justifiable,  and  the  results  gained  are  more  satisfactory 
than  when  the  operation  is  deferred.  It  must  be  evident,  in  com- 
paring the  mortality  and  the  results  of  excision  of  the  hip  with  the  mor- 

' ]  Cent.  f.  Chir.,  1894-96  ;  Congres  de  Chir.,  Proc.  verbale,  481  ;  "  Coxalgie  Tuber- 
culeuse,"  Paris;  Journ.  de  Med.  et  de  Chir.,  Annates,  iv.,  3,  261  ;  Congres  Fr.  de 
Chir.,  1895,  ix.,  153;  Jalaguier:  These  d'Ag.,  Paris,  1868;  Archiv  f.  klin.  Chii., 
xxiv.,  4,  719. 

19 


Fig.  266.— Late  Excision  of  Hip.    Motion  in  flexion  65°.    Shortening 
one  inch.    Walks  without  crutches. 


290 


orthopedic:  surgery. 


tality  and  the  results  of  conservative  treatment,  that  excision  has  no  place 
in  the  routine  treatment  of  the  disease,  because  its  mortality  is  higher  and 
its  functional  results  are  inferior.     The  operation  has,  however,  a  decided 


Fig.  26V. — Late  Excision.    Poor  result.    No  motion.    Hip  painful.    Walks  with  splint, 
since  operation.     (Children's  Hospital  Report.) 


Three  years 


usefulness  in  late  cases  of  hip  disease,  when  it  becomes  distinctly  a  life- 
saving  procedure,  and  in  severe  cases  at  an  early  stage  when  no  home 
treatment  or  adequate  hospital  treatment  for  a  long  time  is  practicable. 

Although  the  writers  have  been  able  to  gain  thoroughly  satisfactory 
results  after  excision  of  the  hip,  and  in  a  few  instances  have  had  reason 


Fig.  368.— Late  Excision  of  the  Hip. 


Bad  result.     Cannot  walk  without  crutch. 
Essay.) 


(Fiske  Prize  Fund 


to  regret  not  having  resorted  earlier  to  excision  in  cases  in  which  conser- 
vative treatment  proved  unsatisfactory,  yet  after  years  of  careful  experi- 
ence in  the  treatment  of  hip  disease  by  both  conservative  and  operative 
methods  they  would  unhesitatingly  record  their  opinion  that  the  conserva- 


HIP   DISEASE. 


291 


tive  method  of  treatment  is  preferable  to  the  operative  and  that  resection 
is  needed  only  in  exceptional  cases. 

Other  operative  procedures  can  be  spoken  of  very  briefly. 

Trephining  into  the  head  of  the  bone  was  proposed  by  Fitzpatrick  in 
18C7,  who  trephined  for  a  short  distance  into  the  great  trochanter  and 
then  attempted  the  destruction 
of  the  diseased  focus  in  the 
head  of  the  femur,  by  treating 
the  bottom  of  the  cavity  thus 
made  by  inserting  a  stick  of 
potassa  cum  calce.  The  same 
end  may  be  reached  by  tunnel- 
ling through  the  trochanter 
into  the  head  of  the  femur 
with  a  drill  or  gouge  and  evac- 
uating any  tuberculous  material 
there.  The  operation  is  a  ser- 
viceable one  and  often  affords 
relief.  It  is  especially  indi 
cated  in  acutely  painful  condi- 
tions of  the  joint,  as  it  relieves 
tension    and    affords   drainage; 

Incision  of  the  Joint. — In- 
cision into  the  hip-joint  is  of 
use  sometimes  in  checking  un- 
controllable night  cries,  and  in 
cases  of  exquisite  sensitiveness 
of  the  joint  in  which  tension  of 
the  capsule  may  be  supposed  to 
exist.  A  straight  incision  is 
made  behind  the  trochanter 
major,  and  after  the  division 
of  the  muscles  the  finger  can 
be  thrust  down  to  the  joint, 
and  on  it  as  a  director  the  capsule  can  be  opened.  The  benefit  from 
simple  incision  will  not  be  found  to  be  great  in  severer  cases. ' 

Amputation. — The  question  of  amputation  of  the  diseased  limb  alone 
remains  for  consideration. 

Neglected  cases  of  hip-joint  disease  occasionally  present  themselves, 
in  which,  owing  to  extensive  tuberculous  disease  of  the  pelvis  or  in  the 
length  of  the  femur,  excision  offers  no  chance  for  a  cure;    in  other  in- 


Fig.  369.— Result  of  Hip  Excision  as  a  Life-saving 
Measure.  One  year  after  operation.  (Fiske  Prize 
Fund  Essay.) 


*E.  H.  Bradford:  Boston  Med.  and  Surg.  Jour.,  August  16th,  1888;  Bost.  Med. 
and  Surg.  Journal,  April  26th,  1885,  392. 


292 


ORTHOPEDIC    SURGERY. 


stances  excision  has  failed  to  arrest  the  destructive  process  in  the  bone, 
and  the  surgeon  is  left  to  choose  between  surrendering  the  patient  to  a 
lingering  and  wretched  death,  and  the  very  radical  measure  of  amputation 
at  the  hip-joint.  In  making  this  choice  he  needs  information  as  to  the 
chances  of  recovery  offered  by  amputation,  and  if  the  operation  is  de- 
cided on,  as  to  the  best  method  of  procedure.  The  former  cannot  be 
found  in  the  ordinary  tables  of  mortality  after  amputation,  as  it  would 
appear  that  the  risk  of  death  is  greater  when  this  operation  is  performed 
after  injury,  or  for  the  removal  of  tumors,  than  when  the  patient  is  freed 
by  the  amputation  from  an  extensively  carious  and  useless  limb,  which 
has  itself  served  as  an  impediment  to  recovery. 

Ashhurst J  collected  34  cases  of  primary  amputation  at  the  hip- joint 
for  hip  disease,  and  31  after  excision,  and  found  19  deaths.  This,  reject- 
ing 5  cases  in  which  the  result  was  undetermined,  would  give  a  mortality 
of  32  per  cent.2  The  death  rate  of  amputation  at  the  hip-joint  after  in- 
jury is  70.9  per  cent,  and  for  disease  in  general,  42.6  per  cent. 

List    of    Amputations    at  the    Hip-Joint    for    Hip    Disease,   not 
Included  in  Ashhurst's  Tables. 


No. 

Surgeon. 

Result. 

Reference. 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

21 

22 

Beddard. 
Bradford. 
F.  Jordan. 

Recovered. 
Died.  . 

British  Medical  Journal,  June  7th,  1884,  p.  1080. 
Boston  Med.  and  Surg.  Journal,  Dec.  11th,  1884,  p. 
British  Medical  Journal,  loc.  cit. 

564. 

ti 

Lediard. 

Littlewood. 

Lloyd. 

Lutz. 

Maclaren. 

Reco 

pered. 

ti              ii             it               .i 

u              ii             u               u 

u              ii             u               ii 
St.  Louis  Med.  and  Surg.  Journ.,  1879,  xxxvii.,  p. 
British  Medical  Journal,  loc.  cit. 

560. 

Marshall. 

n 

British  Medical  Journal,  1885,  xliv.,  p.  220. 

ii              ii             u               ii        it            ii 
ii              u             u               ii        ii            ii 

it 

May. 

Pilcher. 

Roddick. 

Shuter. 

Spofforth. 

Died 
Reco 

vered. 

u              u             u               it        ii            ii 
ii              ii             u               it        u            .i 
British  Medical  Journal,  June  7th,  1884,  p.  1080. 

Philadelphia  Medical  News,  1885,  xlvi.,  p.  220. 
Clinical  Society  Transactions,  1882-83,  xvi.,  p.  86 
British  Medical  Journal,  1884,  p.  1080. 

According  to  Ashhurst,  in  60  cases  there  were  19  deaths ;  in  the  table 
of  later  cases,  22  cases,  with  3  deaths;  making  a  total  of  82  cases,  with 
22  deaths ;  giving  a  mortality  of  27  per  cent,  and  in  the  22  more  recent 
cases,  not  before  1880,  a  mortality  of  only  14  per  cent.       Still  more 

1(<  International  Encyclopedia  of  Surgery,"  vol.  iv.,  p.  501. 
2  One  of  these  nineteen  fatal  cases  (that  of  Buffos)  should  strictly  be  considered 
an  operative  success,  as  death  did  not  take  place  till  three  months  after  the  operation. 


HIP   DISEASE.  293 

recently  the  statistics  of  Wyeth  '  and  Levison2  show  a  mortality  for  the 
operation  by  Wyeth's  method  of  11  in  85 — 15.29  per  cent.  In  recent 
series  in  which  other  methods  have  been  used  the  mortality  remains  con- 
siderably higher  than  this.3  The  mutilation  which  results  is  the  chief  ob- 
jection to  the  operation,  and  is  but  partially  met  by  an  artificial  limb.  An 
undoubted  reformation  of  bone  has  taken  place  in  the  case  operated  upon 
by  one  of  the  writers. 

Absolute  economy  of  blood — of  the  utmost  importance  in  all  hip  am- 
putations— is  vital  in  cases  reduced  to  the  physical  extremity  seen  in 
cases  of  hip  disease  undergoing  this  operation.  The  method  of  disarticu- 
lating, so  popular  in  the  operating  classes,  and  known  as  Lisfranc's  meth- 
od, is  not  readily  done  if  an  elastic  tourniquet  is  used.  To  check  all 
bleeding,  it  will  be  found  most  convenient  to  amputate  as  if  at  the  upper 
part  of  the  thigh,  and  tie  all  bleeding  points,  removing  the  remaining 
fragment  by  a  lateral  incision.  Or  a  lateral  incision  is  made  as  in  exci- 
sion of  the  head  of  the  femur,  the  head  of  the  femur  is  excised  in  order  that 
it  may  be  out  of  the  way,  the  lateral  incision  is  prolonged  and  the  shaft 
of  the  femur  separated  for  two  or  three  inches  in  its  length  from  the  sur- 
rounding muscles,  taking  care  that  the  periosteum  remain  with  the  mus- 
cles. A  circular  amputation  of  the  thigh  is  then  done,  the  bone  sawn 
through,  or  if  entirely  freed  from  the  surrounding  tissues  by  the  lateral 
incision,  pulled  out  from  the  flaps.  The  vessels  are  tied  and  the  tourni- 
quet is  removed. 

For  controlling  hemorrhage  neither  digital  compression  nor  abdominal 
tourniquets  are  to  be  trusted,  although  the  former  can  be  used  in  children 
with  less  risk  than  in  adults.  A  more  serviceable  way  is  that  described 
by  Jordan  Lloyd.4 

The  limb  should  be  elevated  and  stripped  of  blood,  and  an  elastic 
"bandage  is  doubled  and  passed  between  the  thighs,  its  centre  lying  be- 
tween the  tuber  ischii  of  the  side  to  be  operated  upon  and  the  anus.  A 
pad  in  the  shape  of  a  roller  bandage  is  tied  over  the  external  iliac  artery, 
the  ends  of  the  rubber  are  drawn  tightly  upward  and  outward  (one  in 
front  and  one  behind)  to  a  point  above  the  centre  of  the  iliac  crest  of  the 
same  side.  The  front  part  of  the  band  passes  across  the  compress,  the 
back  part  runs  across  the  great  sciatic  notch  and  prevents  bleeding  from  the 
branches  of  the  internal  iliac.  The  ends  of  the  bandage  are  tightened, 
and  should  be  held  by  the  hand  of  an  assistant  placed  just  above  the  centre 
of  the  iliac  crest. 

The  danger  of  hemorrhage  may  be  still  further  diminished  by  trans- 
fixing the  thigh  from  side  to  side  above  the  line  of  incision  and  securing 


1  Wyeth:  Ann.  of  Surgery,  xxv.,  1897,  127. 

2  Levison:  Jour.  Am.  Med.  Assn.,  June  24th,  1899,  p.  1428. 

3Erdman:  Arm.  of  Surgery,  September,  1895.  4 Lancet,  May  26th,  1883. 


291  ORTHOPEDIC   SURGERY. 

pressure  with  a  steel  skewer  passing  under  the  vessels.  If  rubber  tubing 
be  passed  tightly  around  the  ends  of  the  skewer  over  the  anterior  surface 
of  the  thigh  the  front  vessels  can  be  compressed  and  the  same  method 
can  be  applied  to  the  posterior  vessels  (Wyeth's  method).  The  operation 
in  this  way  can  be  performed  without  the  loss  of  any  appreciable  amount 
of  blood,  and  there  is  time  for  due  deliberation,  as  there  is  no  danger  of 
a  death  upon  the  table  by  a  sudden  gush  of  hemorrhage. 

The  operation  of  amputation  at  the  hip-joint  lias  been  performed  three 
times  at  the  Boston  Children's  Hospital  in  extensive  disease  of  the  hip 
and  pelvis,  with  operative  success  in  all,  but  with  ultimate  death  from 
amyloid  disease  in  two  cases.  Ultimate  recovery  took  place  in  one  who 
grew  to  manhood  and  at  twenty  wore  an  artificial  limb  fitted  to  a  stump 
in  which  reformation  of  the  bone  took  place  from  the  periosteum. 

The  following  conclusions  would  appear  to  be  justified :  amputation  at 
the  hip- joint,  in  hip  disease,  should  be  regarded  as  the  very  last  resort, 
contraindicated  by  extensive  amyloid  degeneration  of  the  viscera,  or  a 
moribund  condition  of  the  patient.  The  chances  of  mortality  are  not 
greater  than  those  in  amputation  of  the  thigh  in  general,  and  the  chances 
of  a  permanent  cure  (barring  the  mutilation)  would  appear  to  be  greater 
than  after  excision  at  the  hip- joint.  The  amputation  should  be  done 
subperiosteally  whenever  it  is  possible.  An  elastic  tourniquet  with 
transfixion  by  long  needles  gives  the  best  means  of  preventing  hemor- 
rhage. Preliminary  excision  of  the  head  of  the  femur,  in  freeing  the 
upper  part  of  the  shaft,  will  be  found  to  facilitate  the  amputation. 

Summary. — It  is  difficult  to  summarize  the  treatment  of  hip  disease, 
for  the  reason  that  cases  differ  greatly  in  severity ;  some  needing  recum- 
bency for  a  very  long  period,  owing  to  a  severe  degree  of  sensitiveness  or 
to  the  activity  of  the  ostitis,  while  in  other  cases  ambulatory  treatment 
with  proper  appliances  is  sufficient  without  recumbency. 

The  proper  treatment  of  hip  disease  is,  therefore,  not  the  exclusive 
use  of  any  splint,  but  the  use  of  such  means  as  may  meet  the  indications 
as  they  are  present.  During  the  acute  stages,  the  hip-joint  should  be 
fixed  efficiently  in  bed.  This  implies  the  use  of  thorough  traction.  Con- 
tinued confinement  to  bed  is  not  beneficial  to  the  general  condition  of 
tuberculous  patients,  except  temporarily  during  the  acute  stage ;  and  as 
soon  as  the  acute  symptoms  have  subsided  the  patient  should  be  allowed 
to  go  about  with  the  hip  thoroughly  protected  against  jar  and  spasm. 
This  can  be  done  by  means  of  a  traction  splint,  if  efficiently  applied,  with 
at  first  the  additional  protection  from  crutches. 

If  the  acute  symptoms  return  under  this  method,  thorough  rest  in  bed 
is  again  indicated  in  addition  to  efficient  traction  and  fixation.  If  the 
acute  symptoms  diminish  and  there  is  less  muscular  rigidity  at  the  hip- 
joint,  greater  freedom  can  again  be  allowed,  and  eventually  traction  dis- 
continued, and  the  joint  merely  protected  from  jar.     This  should  be  con- 


HIP   DISEASE.  295 

tinued  so  long  as  there  is  any  danger  of  recurrence  of  active  symptoms 
or  tendency  to  contraction. 

In  brief,  the  hip  should  be  fixed  as  long  as  it  is  sensitive,  should  be 
protected  and  distracted  as  long  as  there  is  muscular  spasm,  and  protected 
as  long  as  it  is  weak.  The  best  results  are  attained  only  by  thorough 
treatment  for  a  year  at  least,  and  careful  supervision  and  protection  for 
two  or  three  subsequent  years.  Distortions  of  the  limb  should  always 
be  corrected  as  they  occur.  In  many  cases  some  motion  can  be  saved  at 
the  hip-joint  if  treatment  is  not  discontinued  too  soon.  Abscesses  can  be 
treated  on  general  surgical  principles.  Eadical  operative  measures  are 
needed  only  in  exceptional  cases  if  thorough  conservative  treatment  can 
be  secured.  Out-of-door  air  and  the  best  obtainable  surroundings  are  of 
great  importance. 


CHAPTER  VI. 

OTHER   DISEASES    OF   THE    HIP-JOINT. 

Synovitis. — Arthritis  deformans. — Charcot's  disease. — Acute  arthritis. — Malignant 
disease. — Bursitis. — Coxa  vara. — Fracture  of  the  neck  of  the  femur  in  children. 

Synovitis. 

Acute,  subacute,  and  chronic  synovitis  of  the  hip-joint  occur  at  times. 

Acute  synovitis  occurs  as  the  result  of  trauma,  and  after  dislocations  of 
the  joint;  acute  synovitis  of  the  hip  occurs  at  times  in  rheumatism  (mon- 
articular or  polyarticular),  in  gonorrhoea,  and  under  the  same  conditions 
existing  in  other  joints  in  general. 

The  symptoms  of  acute  synovitis  of  the  hip-joint  are  not  to  be  distin- 
guished from  those  of  acute  hip  disease  in  many  instances.  More  or  less 
complete  muscular  fixation,  pain  on  motion,  atrophy  of  the  muscles,  and 
even  night  cries  may  be  present. 

Chronic  synovitis  of  the  hip-joint  results  most  often  from  a  continu- 
ance of  the  acute  form.  A  chronic  sprain  of  the  hip  is  often  the  accom- 
paniment of  the  convalescence  from  impacted  fracture  of  the  neck  of  the 
femur.  In  the  case  of  a  young  man  under  the  observation  of  one  of  the 
writers,  months  after  all  bony  repair  had  been  ended,  a  chronic  synovitis 
of  the  joint  persisted,  which  was  relieved  by  treatment  protecting  the 
joint.  The  extent  of  the  synovitis  and  its  course  depend  much  upon  the 
nature  and  amount  of  the  injury  and  the  condition  of  the  patient.  In 
patients  with  tuberculous  predisposition,  such  injuries  may  produce  tuber- 
culous joint  disease.  In  most  cases,  a  synovitis  passes  away  without  per- 
manent injury. 

Diagnosis. — In  the  adult,  chronic  synovitis  might  be  diagnosticated 
after  a  severe  sprain  of  the  joint  in  which  the  symptoms  of  an  acute  syno- 
vitis had  clearly  been  present  and  had  passed  on  to  the  chronic  stage. 
When  there  is  much  distention  of  the  capsule,  swelling  may  be  found  in 
the  groin  below  Poupart's  ligament  and  behind  the  great  trochanter. 
Flexion  of  the  thigh  is  generally  present,  due  to  muscular  fixation  holding 
the  thigh  in  that  position.     The  affection  is  not  common  even  in  adults. 

In  children  the  diagnosis  of  synovitis  of  the  hip- joint  should  be  made 
only  when  recovery  has  occurred  in  a  few  weeks  and  has  proved  perma- 
nent. 

Treatment. — The  treatment  can  be  summed  up  in  a  very  few  words. 


OTHER   DISEASES   OF   THE    HIP-JOINT.  297 

In  children  cases  of  synovitis  of  the  hip-joint  are  to  be  treated  in  the 
same  way  as  cases  of  tuberculous  ostitis. 

Cases  in  adults,  which  are  clearly  to  be  recognized  as  synovitis,  should 
be  treated  by  rest  to  the  joint,  including,  if  necessary,  either  traction  or 
protection  by  apparatus,  and  counter-irritation,  blisters,  etc.,  back  of  the 
trochanter.  And  every  care  should  be  taken  to  guard  against  using  the 
unprotected  limb  too  soon. 

Arthritis  Deformans. 

Arthritis  deformans  of  the  hip-joint  is  an  affection  which  is  not  un- 
common in  patients  above  the  age  of  forty-five.  It  may  occur  as  a  mon- 
articular affection  or  in  connection  with  a  simultaneous  affection  of  some 
of  the  other  joints. 

Pathology  and  Etiology. — When  affecting  the  hip  it  is  known  as  senile 
coxitis,  malum  coxse  senile,  chronic  rheumatoid  arthritis  of  the  hip,  etc. 
It  begins  in  many  cases  insidiously,  while  in  others,  and  especially  mon- 
articular cases,  it  follows  after  a  fall  upon  the  trochanter.  From  the 
shortening  of  the  head  and  neck  in  these  cases  it  was  supposed  by  some 
writers  to  be  an  impacted  fracture  of  the  neck  of  the  femur,  but  the 
shortening  results  from  the  absorption  of  the  head  and  is  in  every  way 
like  the  pathological  changes  found  in  the  insidious  cases. 

There  are  apparently  two  classes  of  cases,  basing  the  distinction  on 
the  pathological  appearance  of  a  large  number  of  specimens.  One  class 
comprises  those  cases  in  which  the  hypertrophic  changes  predominate. 
These  consist  in  an  enlargement,  thickening,  and  increase  in  density  of 
the  head  of  the  femur.  In  the  second  class  the  atrophic  changes  predomi- 
nate. The  bone  is  lighter  and  is  usually  light  and  porous,  or  spongy, 
and  the  head  and  neck  of  the  bone  are  diminished  in  size. 

There  are  other  cases  which  seem  to  hold  an  intermediate  position, 
and  in  which  both  the  hypertrophic  and  atrophic  changes  are  combined. 

Symptoms. — The  affection  begins  with  pain  m  and  about  the  joint, 
often  shooting  down  the  course  of  the  sciatic  nerve  at  the  back  of  the 
leg  instead  of  down  the  front  as  in  epiphyseal  ostitis.  At  this  stage  the 
affection  very  closely  simulates  sciatic  neuralgia.  Movements  of  the 
joint  beyond  a  certain  arc  are  painful,  and  a  noticeable  limp  is  present. 
Flexion  and  eversion  are  particularly  painful  movements  to  the  patient, 
and  if  the  leg  is  manipulated  a  distinct  creaking  is  sometimes  felt  which 
is  most  noticeable  when  the  movements  are  most  painful. 

Muscular  atrophy  of  the  limb  comes  on  and  the  nates  of  the  affected 
side  are  flaccid  and  flattened,  and  apparent  shortening  from  flexion  and 
adduction  is  present  in  the  diseased  limb,  as  well  as  true  bone  shortening. 
Muscular  fixation  is  at  first  not  a  prominent  symptom,  except  in  very 
sensitive  conditions  of  the  joint,  but  the  arc  of  motion  gradually  dimin- 


298  ORTHOPEDIC   SURGERY. 

ishes  until  finally  the  joint  becomes  entirely  stiff!  in  perhaps  a  normal 
position,  or  perhaps  adductecl  or  flexed.  In  the  earlier  stages  abduction 
and  apparent  lengthening  of  the  limb  may  be  present  as  in  hip  disease. 

The  position  which  the  limb  assumes  in  the  more  advanced  cases  of 
the  disease  is  one  which  is  calculated  to  be  most  misleading,  especially 
when  the  affection  has  followed  a  fall  upon  the  trochanter.  The  limb  is 
rotated  outward  and,  with  the  apparent  shortening,  presents  almost  a  com- 
plete picture  of  an  impacted  fracture  of  the  neck  of  the  femur.  In  other 
instances  the  thigh  may  be  flexed  and  adducted  as  in  hip  disease  proper. 

Arthritis  deformans  of  the  hip-joint  does  not  go  on  to  suppuration. 

Diagnosis. — The  affection  is  likely  to  be  confused  with  sciatica  and 
impacted  fracture  of  the  neck  of  the  femur. 

In  sciatica  the  limitation  of  motion  is  governed  by  the  amount  of  pain 
produced  by  the  movement  of  the  sensitive  parts  and  by  the  tension  on 
the  nerve,  and  therefore  differs  from  that  resulting  from  true  hip- joint 
disease.  Flexion  is  usually  free  to  a  certain  limit,  but  impossible  beyond 
this  and  if  the  leg  is  held  extended  on  the  thigh  this  is  particularly 
noticeable.  In  sciatica,  hyperextension  is  not  interfered  with,  nor  rota- 
tion nor  lateral  motion.  The  diagnosis  from  true  hip  disease  is  based 
chiefly  on  the  patient's  age;  tuberculous  epiphyseal  ostitis  being  quite 
rare  in  adults  except  in  connection  with  well-marked  tuberculous  disease. 

From  impacted  fracture  of  the  neck  of  the  femur  the  diagnosis  may 
be  almost  impossible  except  for  the  history  of  the  case  and  upon  general 
surgical  principles.     There  are  no  definite  differential  signs. 

Treatment. — Morbus  coxae  senilis  or  arthritis  deformans  demands 
treatment,  first  to  relieve  the  pain,  and  secondly  to  correct  the  deformity. 

The  symptom  of  pain  is  rarely  so  great  as  to  cause  disability.  In 
such  cases  hot  baths,  massage,  galvanism,  hot  packs,  and  the  adminis- 
tration of  the  remedies  recommended  in  the  treatment  of  chronic  rheu- 
matoid arthritis  are  often  of  use.  The  use  of  crutches  and  canes  will 
often  be  needed.  The  deformities  which  follow  this  affection  are  usually 
those  seen  in  hip  disease,  but  they  are  more  gradual  in  development. 
They  are  persistent  and  obstinate,  but  are  amenable  to  proper  mechanical 
treatment,  such  as  is  used  in  the  deformities  of  hip  disease. 

H.  L.  Taylor1  has  related  several  cases  in  which  rest  to  the  joint  was 
afforded  by  recumbency  and  traction  and  afterward  the  joint  was  pro- 
tected for  a  long  time  by  a  simple  protection  apparatus  like  that  advo- 
cated for  use  in  convalescent  hip  disease.  The  results  were  favorable  in 
the  extreme.  Joint  irritation  from  overuse  is  to  be  met  here  as  elsewhere 
by  rest  to  the  joint. 

More  is  to  be  gained  ordinarily  by  gradual  correction  by  mechanical 
means  than  by  forcible  straightening  in  this  class  of  affections  of  the  hip. 

"'Senile  Coxitis,"  N.  Y.  Med.  Jour.,  December  15th,  1888. 


OTHER   DISEASES   OF   THE   HIP-JOINT.  299 

Charcot's  Disease  of  the  Hip-Joint. 

In  frequency  of  attack  the  hip  comes  next  to  the  knee,  which  among 
the  large  joints  is  the  one  most  often  affected.  As  in  most  other  instances, 
Charcot's  disease  of  the  hip  simulates  very  closely  arthritis  deformans  of 
the  ordinary  type.  The  changes  in  the  joint  are,  however,  much  more 
acute  and  extensive  than  those  with  which  we  are  familiar  in  arthritis 
deformans.  Synovial  effusion  is  a  more  prominent  symptom,  sometimes 
reaching  the  stage  of  large  fluctuating  tumor  which  presents  itself  at  the 
front  and  the  back  of  the  joint,  with  a  wearing  away  of  the  head  of  the 
bone.  The  trochanter  ascends  and  a  state  of  affairs  similar  to  the  condi- 
tion found  in  late  hip  disease  is  presented.  In  the  matter  of  diagnosis,  of 
course  one  depends  upon  the  coexistence  of  symptoms  of  spinal-cord  dis- 
ease. As  to  treatment,  nothing  can  be  accomplished;  in  cases  in  which 
swelling  is  excessive,  aspiration  of  the  joint  sac  may  give  temporary 
relief.  In  cases  in  which  syphilitic  history  is  present,  mercury  or  iodide 
of  potassium  should  be  given.  Rest  is  indicated  for  the  joint,  with  trac- 
tion if  it  gives  relief.  4 

Acute  Arthritis 

may  occur  in  the  hip  in  early  infancy.  It  does  not  differ  from  its  usual 
course  when  situated  in  the  hip  except  in  its  tendency  to  dislocate  the  hip 
or  destroy  the  head  of  the  femur.  Such  cases  later  in  life  may  simulate 
closely  congenital  dislocation  of  the  hip.  When  dislocation  occurs,  re- 
placing the  head  of  the  femur  and  nailing  it  in  place  may  be  done,  as  in 
a  successful  case  reported  by  A.  Thorndike. 

The  other  inflammations  which  may  affect  the  hip  deserve  no  separate 
mention  from  that  already  given  them. 

Malignant  Disease  op  the  Hip 

is  a  rare  affection. 

The  variety  of  tumor  which  most  often  affects  the  head  of  the  femur 
in  young  children  is  a  round-cell  sarcoma  of  the  periosteum.  But  the 
epiphysis  is  rarely  the  seat  of  the  tumor.  In  seventy  cases  of  sarcoma 
of  the  femur,  analyzed  by  Gross,  there  were  only  two  cases  in  which  the 
upper  epiphysis  was  affected.' 

The  early  symptoms  in  cases  in  which  the  head  of  the  femur  is  not 
primarily  involved  are  very  slight  and  consist  chiefly  of  a  swelling  which 
is  painless  and  not  fluctuating ;  limp  and  slight  restriction  of  motion  may 
be  present.  Soon,  however,  it  becomes  evident  that  the  enlargement  is 
predominating  over  all  the  other  symptoms  and  the  swelling  progressively 
increases,    suggesting    perhaps   hip   abscess.     Fluctuation,    however,    is 

1  Am.  Joum.  Med.  Sci.,  July  and  October,  1879. 


300 


ORTHOPEDIC    SURGERY. 


absent  and  the  swelling  embraces  the  whole  circumference  of  the  limb. 
There  is  an  enlargement  of  the  superficial  vessels  and  the  swelling 
later  becomes  enormous.  The  patient  becomes  emaciated  and  wastes 
away.  The  affection  may  be  very  painful  or  again  it  may  be  attended 
with  very  little  suffering.  Amputation  at  the  hip- joint,  if  performed 
sufficiently  early,  is  the  only  remedy,  but  offers  little  hope  of  success. 


Fig.  370.— Specimen  of  Coxa  Vara.     No  clinical  history. 

Loose  Cartilages 

in  the  hip-joint  are  so  exceptional  as  to  be  simply  anatomical  curiosities. 
The  symptoms  are  similar  to  those  described  under  the  head  of  loose 
bodies  in  other  joints.     Their  removal  by  operation  is  not  easy. 


Bursitis. 

Inflammation  of  the  bursa?  about  the  hip-joint  must  be  recognized  as  a 
condition  likely  to  give  rise  to  symptoms  possibly  resembling  hip  dis- 
ease. '  This  inflammation  is  most  often  traumatic,  but  may  be  tubercu- 
lous. Suppuration  and  the  formation  of  fistulse  may  occur.  According 
to  the  location  of  the  inflammation  the  symptoms  will  differ. 


1  Deutsck.  Zeit.   f.  Chir.,  December,  1898;  Brackett:  Trans.  Am.   Orth.  Assn., 


1896. 


OTHER   DISEASES    OF    THE    HIP-JOINT. 


301 


The  chief  bursse  about  the  hip  areas  follows:  The  subiliae  burs;*; 
under  the  ilio-psoas  tendon  as  it  leaves  the  pelvis ;  the  bursa  under  the 
insertion  of  the  tendon  of  the  ilio-psoas.  About  the  trochanter  major 
there  are  several:  one  between  the  fascia  lata  and  the  skin;  a  less  con- 
stant one  between  the  fascia  lata  and 
the  trochanter ;  one  under  the  gluteus 
medius ;  one  under  the  tendon  of  the 
gluteus  minimus;  one  between  the  ob- 
turator externus  and  the  gemelli ;  one 
for  the  pyrif ormis ;  one  for  the  obtu- 
rator internus.  A  bursa  further  re- 
moved from  the  hip-joint,  but  one  like- 
ly to  be  affected,  is  one  between  the 
gluteus  maximus  and  the  tuberosity 
of  the  ischium.  This  affection  may  be 
mistaken  for  hip  disease,  as  there  is 
limitation  of  motion  and  limp,  and,  in 
the  severest  cases,  suppuration.  The 
diagnosis  at  times  can  be  established 
only  after  incision.  The  treatment  con- 
sists of  the  temporary  use  of  crutches 
and  incision  in  the  severer  cases. 

Coxa  Vara 

is  the  name  applied  to  a  deformity 
caused  by  the  bending  of  the  neck  of 
the  femur  so  that  the  normal  relation 
between  the  head  of  the  femur  and  the 
shaft  is  changed.  The  yielding  gen- 
erally results  in  the  upward  and  back- 
ward movement  of  the  trochanter  and 
shaft.  This  is  naturally  represented 
clinically  by  an  elevation  of  the  tro- 
chanter above  Nelaton's  line,  by  ever- 
sion  of  the  whole  limb,  by  shortening 
of  the  limb,  and  by  a  limitation  of  ab- 
duction of  the  leg.  The  displacement 
may,  however,  be  upward  or  even  up- 
ward and  forward.1  In  the  latter  case  eversion  rather  than  inversion  is 
limited. 

In  96  cases  collected  by  Whitman  there  were  74  males  and  22  females. 
In  23  the  deformity  was  bilateral,  and  in  73  unilateral.     In  2  cases  there 


Fig.  271.— Photograph  of  Case  of  Coxa  Vara. 
(Whitman.) 


1  Whitman  :  N.  Y.  Med.  Journ.,  January  21st,  1899. 


302 


ORTHOPEDIC  SURGERY 


**' 


Fig.  272. 
men. 


-Outline  of  Depressed  Neck  of  Femur  in  Miiller's  Speci- 
Contrasted  with  normal  (in  dotted  line).    (Whitman.) 


agnostic  signs  become  evident, 
thigh.     These  are  shortening 
of    the  limb,   elevation  and 
prominence  of  the  trochan- 
ter, outward  rotation  of  the 


were  2  adults,  15  ado- 
lescents, 7  from  5  to  11 
years,  and  2  less  than  5 
years  old.* 

It  occurs  most  often 
in  adolescence  but  also 
in  childhood,  and  has 
been  described  as  con- 
genital,1 in  the  latter 
case  in  connection  with 
rickets. 

In  adolescents  after 
a  fall  or  strain,  or  often 
without  cause,  a  stiff- 
ness and  soreness  in  one 
or  both  hips  may  be  no- 
ticed. At  first  it  simu- 
lates an  inflammatory 
affection.  Later  the  di- 
This  is  especially  noted  on  flexing  the 


Fig.  273.— Outline  of  the  Deformity  in 
Holla's  Specimen.  Dotted  line  shows 
normal  position.     (Whitman.) 


Fig.  274.— Cross  Section  of  Pelvis  and  Deformed 
Femur.  A  scheme  to  show  the  effect  of  the  deform- 
ity in  limiting  abduction.  Dotted  outline  shows  the 
normal  relation.     (Whitman.) 


•Krebel:  "Coxa  vara  congenita,"  Cent.  f.  Chir.,  October  17th,  1896. 


OTHER   DISEASES    OF    THE    HIP-JOINT. 


303 


leg,  ofteuest  with  eversion  of  the  foot,  and  limitation  of  abduction  due 
to  the  nearness  of  the  trochanter  to  the  ilium.  When  both  sides  are 
affected  lordosis  may  be  present  and  a  swaying  gait  simulating  spastic 
paralysis. 

In  bilateral  cases  the  deformity  may  be  so  marked  that  cross-legged 
progression  is  necessary. 

Among  other  symptoms  to  be  mentioned  are  joint  irritation,  pain,  and 
fatigue.  The  shortening  sometimes  in  itself  is  a  cause  of  discomfort  and 
of  limping.      Scoliosis  may  occur  secondarily  as  a  result  of  the  short  leg. 

The  cause  of  the  process  which  allows  the  bone  to  yield  is  by  no  means 
clear.      In  specimens  of  the  deformity  obtained  by  resection1  there  has 


Fig.  275.— Same  Case  as  Fig.  ~T4,  Showing  Involuntary  Crossing  of  the  Legs  in  Flexion.    (Whitman.) 


been  no  evidence  of  disease  in  the  joint  or  bone  structure,  except  in 
Keetly's2  case,  in  which  a  wedge  of  bone  from  the  neck  of  the  femur,  re- 
moved to  correct  the  deformity,  is  said  to  have  shown  "  evidence  of  local 
rhachitis."  In  general,  it  appears  that  the  evidence  in  favor  of  local 
rickets  as  a  cause  is  not  convincing  when  the  signs  of  general  rickets  are 
absent.3  In  general  rickets  this  deformity  does  occur,  although  it  is  not 
common  to  find  it  present  to  a  marked  degree. 

Other  causes  which  may  produce  the  deformity  are  of  course  fract- 
ure of  the  neck  of  the  femur,  ostitis,  osteomyelitis,  *  osteomalacia,  and 

1  Koser:  Schmidt's  Jahrbuch,  Leipsic,  1843,  p.  257  ;  Zeis,  quoted  by  Whitman. 
'2  Quoted  from  Whitman:  Orth.  Trans.,  vol.  vii.,  p.  288. 
3 Munch,  med.  Woch.,  1890,  x.,  93. 
4Hoffa:  Zeitsch.  f.  Orth.Chir.,  i.,  55. 


304 


ORTHOPEDIC   SURGERY. 


ostitis  deformans,  or  ostitis  fibrosa  (Ki'ister).     There  is  no  agreement  as 

to  the  etiological  factor  in  cases  not  falling  into  these  obvious  classes. 

Kocher    has    found    microscopical    evidence    of    juvenile    osteomalacia. 

Kirmisson  and  Charpentier  believe  that  in  certain  cases  arthritis  defor- 
mans exists.  Certain  cases  ex- 
amined have  shown  congestion 
and  softening  and  slight  irreg- 
ularity of  the  epiphyseal  carti- 
lage, but  apparently  no  more 
than  might  be  found  in  bone 
bending  as  the  result  of  over- 
strain. ' 

Relative     slenderness     and 
weakness    of    the    neck  of  the 


Fig.  277.— Fracture  of  Hip  Four  Years  after 
the  Accident.  Shows  Eversion.  (Whit- 
man.) 


Whitman:  N.  Y.  Med.  Journ.,  January  21st,  1880. 


OTHER   DISEASES    OP   THE   HIP-JOINT. 


?>or> 


femur,  a  normally  varying  angle  between  the  neck  and  shaft  of  the 
femur,  and  the  fact  that  a  certain  amount  of  descent  of  the  neck  of  the 
femur  is  normal  during  adolescence,  all  suggest  themselves  as  being  pos- 


1 


sible  factors  in  predisposing  to  the  deformity.  Injury,  sudden  strain, 
and  constant  overwork  might  act  in  such  cases  to  produce  a  yielding  of 
the  neck  of  the  femur.1 

In  certain  cases,  however,  the  yielding  has  been  found  rather  in  the 


'Mikulicz:    Areh.   f.   klin.   Chir.,  xxiii.,  S.   561;    Arndt :  Wien. .  med.  Presse, 
April  6th,  1890;  Humphrey:  Jour.  Anat.  and  Phys.,  xxiii..  1889.  p.  236;  Humph- 
rey:  Loc.  cit.  ;  Lane:   Trans.  Path.  Soc,  London,  1886,  446 ;   Wien.  med.  Presse, 
January  26th,  1868. 
20 


306 


ORTHOPEDIC   SURGERY. 


junction  with  the  epiphysis  of  the  head  of  the  femur  with  the  shaft  than 
in  any  change  in  the  angle  of  the  neck.1 

The  affection  is  most  likely  to  be  mistaken  for  congenital  dislocation 
of  the  hips,  or  hip  disease. 

In  congenital  dislocation  the  disability  exists  from  birth,  the  hip- 
joints  are  unduly  lax,  and  traction  pulls  down  the  femur  in  relation  to  the 
pelvis.      Moreover,  the  dislocated  head  of  the  femur  can  be  identified 

through  the  soft  parts.     The  .r-ray  offers 
a  means  of  diagnosis. 

In  hip  disease  the  limitation  of  mo- 
tion is  generally  in  all  directions;  in 
coxa  vara  abduction  is  chiefly  affected, 
and  unless  joint  irritation  is  present, 
this  limitation  is  not  the  result  of  mus- 
cular spasm.  Coxa  vara  with  irritation 
of  the  hip-joint  is  difficult  to  differenti- 
ate from  hip-joint  disease. 

From  fracture  of  the  neck  of  the 
femur  in  its  later  stages  the  affection 
cannot  always  be  accurately  diagnosti- 
cated in  obscure  cases. 

The  prognosis  without  treatment  is 
not  good,  as  an  increase  of  the  deform- 
ity is  likely. 

The  treatment  consists  in  an  oste- 
otomy and  correction  of  the  deformity 
in  the  severer  cases. 

Osteotomy  may  be  a  wedge-shaped 
osteotomy  of  the  neck  of  the  femur 
(Kraske),  or  a  linear  osteotomy  of  the 
neck  of  the  femur,  or  a  linear  subtro- 
chanteric osteotomy  with  abduction  of 
the  limb  to  obviate  the  shortening  of  the 
limb. 


Fig.  279.— Fracture  of  Hip.  Projection 
and  elevation  of  trochanter.  (Whit- 
man.) 


Fracture  of  the  Keck  of  the  Femur 
in  Children. 


Malposition  after  fracture  of  the 
neck  of  the  femur  in  children  must  be 
recognized  as  the  cause  of  a  deformity  similar  to  that  of  coxa  vara.  At- 
tention has  been  called  to  the  subject  by  Whitman.2  He  believes,  and 
is  supported  in  this  by  his  .r-ray  pictures  and  measurements,  that  frac- 

'Kocher,  Hofmeister,  Nasse :  Quoted  by  Hoffa,  "Orth.  Chir.,"  1898,  p.  606. 
2  Orth.  Trans.,  vol.  x.,  p.  221. 


OTHEK   DISEASES    OF   THE   HIP-JOINT.  307 

ture  of  the  neck  of  the  femur  has  occurred  rather  than  epiphyseal  sepa- 
ration. Symptoms  of  joint  irritation  are  generally  added  to  those  of  the 
injury  alone  as  a  result  of  the  use  of  the  leg,  and  if  walking  is  kept  up 
during  the  process  of  repair  marked  sinking  of  the  neck  of  the  femur 
may  occur.  In  an  adolescent  patient  under  the  care  of  one  of  the  writers 
in  whom  an  impacted  fracture  of  the  neck  of  the  femur  had  occurred,  one 
of  the  chief  annoyances  was  the  fact  that  the  affected  leg  must  always  be 
flexed  in  an  abducted  plane.     In  sitting  this  caused  much  inconvenience. 

The  recognition  of  such  fractures  in  children  is  of  much  importance 
and  their  recognition  and  treatment  differ  in  no  radical  way  from  those  in 
older  persons. 

The  operative  treatment  is  similar  to  that  of  coxa  vara. ' 

1Hofmeister:  Beitrage  z.  klin.  Chir.,xii.,  1894,  and  xxi.,  ii.  ;  Frazier:  Annals 
of  Surg.,  July,  1898;  Alsberg:  Zeit.  f.  Orth.  Chir.,  vol.  i.,  1898. 


CHAPTEE  TIL 

TUMOR   ALBUS   OF   THE   KNEE-JOIXT. 

Definition. — Pathology. — Clinical  history. — Diagnosis. — Differential  diagnosis. — 
Prognosis. — Treatment,  (a)  conservative,  (b)  operative  (excision,  —  arthrec- 
toniy, — amputation). 

Definition. 

The  old  term  tumor  albus  is  here  applied  to  the  most  common  of  all 
knee-joint  affections  formerly  known  as  fungous  disease  of  the  knee- 
joint. 

Other  names  are  tuberculosis  of  the  knee-joint,  scrofulous  disease  of 
the  knee,  chronic  purulent  or  fungous  synovitis  of  the  knee,  etc. 

Anatomically,  it  should  be  noted  that  the  joint  surfaces  forming  the 
knee  are  nearly  flat,  and  the  facets  in  the  tibia  shallow.  Owing  to  this 
fact,  the  tibia  is  easily  drawn  backward  and  flexed  by  the  hamstring 
muscles,  the  flexors  of  the  leg  being  much  stronger  than  the  extensors, ' 
at  the  same  time  it  is  rotated  outward,  the  combination  constituting  the 
common  and  troublesome  deformity  which  is  the  characteristic  one  after 
severe  tumor  albus. 

Pathology. 

Tumor  albus,  as  it  is  seen  in  children,  begins  oftenest,  if  not  always, 
as  an  epiphyseal  ostitis  of  the  tuberculous  type.  Like  other  forms  of 
tuberculous  disease,  it  is  oftenest  limited  to  certain  portions  of  the 
epiphysis,  and  either  the  femoral  or  tibial  epijDhysis  may  be  attacked  pri- 
marily. Cases  are  occasionally  seen,  however,  in  which  the  primary  focus 
is  in  the  patella  or  in  the  head  of  the  fibula.2  In  children  it  is  not  un- 
common to  see  an  acute  apparently  traumatic  effusion  gradually  absorbed, 
leaving  an  infiltrated  and  thickened  synovial  sac.  In  the  greater  number 
of  cases,  however,  the  bone  symptoms  clearly  precede  the  effusion. 

The  pathological  appearances  of  tuberculous  joints  have  been  so  fully 
described  in  speaking  of  the  pathology  of  chronic  purulent  synovitis  and 
epiphyseal  ostitis  that  it  is  not  worth  while  to  enter  upon  them  here  to 
any  extent. 

^ucke:  Deutsch.  Zeit.  f.  Chir. ,  March  9th,  1885;  Sonnenbnrg:  Deutsch.  Zeit. 
f.  Chir.,  vii.,  p.  485;  Fischer:  Deutsch.  Zeit.  f.  Chir.,  viii.,  1-37. 
? Nichols:  Orth.  Trans.,  vol.  xi. 


TUMOR   ALBUS   OF   THE   KNEE-JOINT. 


309 


Owing  to  the  large  size  of  the  articular  ends  of  the  bones  which  enter 
into  the  formation  of  this  joint,  it  is  not  uncommon  to  find  sequestra  of 
considerable  size  in  the  bony  ends,  which  are  ordinarily  in  the  form  of 
a  wedge  with  the  base  toward  the  joint.  They  are  not,  however,  the 
accompaniment  of  early  tumor  albus. 

In  the  severer  cases  a  destructive,  fungous,  or  purulent  synovitis  gen- 
erally develops,  which  becomes  the  characteristic  feature  of  the  pror-ess. 
This  may  end  in  a  complete 
destruction  of  the  joint  or  in 
arrest  and  recovery  by  absorp- 
tion and  cicatrization. 

Clinical  History. 

The  affection  begins,  as  a 
rule,  insidiously,  with  stiffness 
and  limp  in  gait.  The  disease 
may  be  limited  for  a  long  time, 
and  be  manifested  by  an  enlarge- 
ment of  the  condyles  or  head  of 
the  tibia,  or  it  may  extend  and 
involve  the  whole  joint;  occa- 
sioning severe  pain,  swelling  of 
the  periarticular  tissues,  effusion 
into  the  joint,  peri-articular  ab- 
scess, and  distortion  of  the  limb, 
i.e.,  flexion  and  subluxation, 
and  ending  in  a  natural'  cure 
with  fibrous  or  bony  ankylosis 
and  a  distorted  limb,  which  may 
be  more  or  less  serviceable,  ac- 
cording to  the  distortion  ;  or  the 
affection  may  result  in  such  ex- 
tensive suppuration  as  to  en- 
danger life  from  septic  or  amy- 
loid changes.  Sometimes  in 
cases  of  moderate  severity  an  attack  of  severe  pains  supervenes,  and  an 
acute  stage  is  reached,  when  the  limb  is  flexed  at  the  knee,  hot  and  ten- 
der to  the  touch,  and  sensitive  to  any  jar.  Under  proper  treatment  this 
stage  gradually  subsides,  and  there  may  be  left  impairment  of  motion. 
Enlargement  of  the  bone,  if  it  persists  for  any  length  of  time,  is  charac- 
teristic of  chronic  epiphysitis  of  the  knee. 

The  swelling  at  the  knee,  unless  suppurative  synovitis  is  present  to  a 
marked  degree,  differs  from  that  of  synovitis  with  effusion,  in  that  the 
swelliug  is  of  the  bone  and  soft  peri-articular  tissues,  and  is  not  alto- 


Fig.  280.— Tumor  Albus.  Joint  showed  general  tu- 
berculous process,  without  visible  connection  with  the 
primary  focus,  a  cavity  in  head  of  tibia  of  three  cen- 
timetres diameter,  rilled  with  cheesy  material,  o. 
Tuberculous  focus  in  femur.     (Nichols.) 


310 


ORTHOPEDIC   SURGERY. 


gether  within  the  joint.  If  the  effusion  is  large,  as  in  chronic  serous 
synovitis,  the  patella,  when  the  muscles  holding  it  are  relaxed,  can  be 
depressed  by  pressing  on  it,  and  be  felt  to  hit  against  the  bone  as  it  floats 
above  the  fluid  within  the  joint.     In  effusion  the  shape  of  the  swelling  is 

characteristic.  When 
effusion  is  the  character- 
istic feature,  it  is  most 
prominent  on  both  sides 
of  the  patella,  and  is 
limited  by  the  tendon  of 
the  quadriceps  extensor 
muscle  and  by  the  liga- 
menturr  patellae. 

In  tumor  albus  the 
chief  symptoms  are  heat, 
swelling,  tenderness,  and 
joint  distention;  while 
in  hip  disease,  the  joint 
being  less  accessible,  a 
different  class  of  symp- 
toms, restriction  of  mo- 
tion, limp,  and  distor- 
tions of  the  limb,  are 
more  to  be  depended 
upon. 

In  tumor  albus  the 
knee  will  be  seen  to  have 
lost  its  definite  contour, 
the  depressions  on  the 
sides  of  the  patella  have 
become  filled  out  so  that 
there  is  an  indistinctness 
of  outline  which  is  as 
perceptible  to  the  touch 
as  to  the  sight.  Most 
often  the  patella  seems 
to  be  raised  from  its  posi- 
tion by  a  semi-solid  mass 
and  the  whole  knee  seems 
surrounded  by  a  boggy  infiltration.  Later  it  assumes  a  spindle  shape 
and  the  distention  causes  the  skin  to  be  somewhat  anaemic  in  the  more 
severe  cases,  whence  the  name  of  tumor  albus. 

In  some  instances,  one  of  the  condyles — usually  the  internal  condyle 
— is  enlarged  more  than  the  other,  causing  knock-knee. 


Fig.  281.— Tuberculous  Knee  in  Adult.  General  synovial  tu- 
berculosis. Large  irregular  area  of  tuberculous  softening  in 
epiphyseal  end  of  femur,  extending  into  joint  along  crucial  lig- 
aments,   o,  Tuberculous  focus.    (Nichols.) 


TUMOR  ALBUS  OF  THE  KNEE-JOINT. 


811 


In  the  milder  cases,  arrest  of  the  disease  may  occur  at  any  time  with 
more  or  less  complete  restoration  of  the  joint.  In  the  severer  cases  sup- 
puration may  follow,  with  the  establishment  of  sinuses.      The  destructive 


Fig.  282.  —  Knee-joint ; 
Excision  for  Deformity 
after  Old  Tumor  Albus. 
Partial  occlusion  of  artery 
by  projecting  spur  of  tibia. 
Gangrene,  a.  Wire  mark- 
ing line  of  popliteal  ar- 
tery ;  b,  line  of  union  of 
femur  and  tibia.  (Nich- 
ols.) 


Fig.  283.— Tuberculous  Knee,  Process  of  Repair  Advanced, 
persists,  a,  Tibia ;  /;,  tuberculous  softening ;  c,  femur ; 
(Nichols.) 


Small  focus 
d,   patella. 


process  may  become  so  extensive  that  excision  or  amputation  is  required. 
In  general,  the  affection  is  favorably  affected  by  proper  treatment. 

Atrophy  of  the  muscles,  both  of  the  thigh  and  calf,  is  present,  and 
reaches  a  serious  degree  in  acute  cases.  It.  is  quite  equally  distributed 
between  the  muscles  of  the  thigh  and  those  of  the  leg. 

Shortening  is  a  much  less  important  factor  than  in  hip  disease,  and 
until  late  in  the  affection  does  not  appear  to  any  extent,  and  this  late 
shortening  comes  as  a  result  of  the  faster  growth  of  the  well  leg  oftener 
than  as  the  outcome  of  bone  destruction.  During  the  course  of  the  dis- 
ease lengthening  of  the  affected  leg  may  occur.  The  hyperemia  occa- 
sioned by  the  inflammation  induces  the  overgrowth  in  all  directions  of 
the  tibial  and  femoral  epiphyses,  so  that  they  outstrip  for  a  while  those 


312 


ORTHOPEDIC    SURGERY. 


A 


of  the  other  leg.  In  measuring  a  child  with  tumor  albus  it  is,  therefore, 
not  uncommon  to  find  the  diseased  leg  half  an  inch  longer  than  the  other. 
Later  in  the  disease,  the  trophic  disturbance  which  occurs  in  all  these 

tuberculous  joint  affec- 
tions makes  itself  felt 
and  the  diseased  leg 
falls  behind  the  well 
one  in  its  growth. 

Pain. — The  pain  of 
the  affection  is,  except 
during  the  acute  exacer- 
bations, not  severe, 
though  pain  on  jarring 
the  limb  is  common. 
Night  cries  are  much 
less  common  than  in  hip 
disease,  but  they  occur. 
When,  however,  the  pa- 
tient does  suffer  from 
an  acute  exacerbation, 
the  pain  and  tenderness 
are  excessive.  From 
the  exposed  condition  of 
the  joint  jars  and  twists 
are  very  common,  and 
the  suffering  may  be  ex- 
treme. Tenderness  is 
very  common,  especially 
over  the  inner  surface  of 
the  head  of  the  tibia. 
In  certain  cases,  how- 
ever, the  knee  is  held 
rigid  by  muscular 
spasm,  and  any  reason- 
able manipulation  fails 
to  occasion  any  pain. 
Heat  of  the  affected  joint  is  present  and  is  a  most  valuable  index  of 
the  progress  of  a  case.  It  can  be  easily  felt  with  the  hand  as  long 
as  the  disease  is  active,  but  when  it  becomes  quiescent  it  disappears, 
to  return  if  anything  goes  wrong.  It  can  be  felt  to  diminish  if  treat- 
ment is  successful  in  quieting  the  condition  of  the  joint,  and  is  a  most 
urgent  indication  for  protective  treatment  so  long  as  it  exists  in  any 
degree. 

Lameness  is  a  constant  symptom.     It  varies  with  the  sensitiveness  of 


•■>i^'J 


Fig.  284.— Tumor  Albus.    Appearance  of  dry  bones. 


TUMOR    ALBUS    OF   THE    KNEE-JOINT. 


313 


the  joint  and  is  much  influenced  by  the  amount  of  flexion   present  in  the 
diseased  knee. 

Muscular  fixation,  is  a  symptom  of  this  as  of  all  chronic  tuberculous 
ostitis,  but  is  less  prominent  than  in  the  hip.  In  the  early  stages  it  may 
be  practically  absent.  The  joint  may  be  held  perfectly  rigid  in  full  ex- 
tension or  in  partial  flexion,  or  a  certain  arc  of  motion  may  be  permitted 
and  then  the  muscles  quickly  catch  the  joint  and  prevent  it  from  going 


Fig.  285.— Tumor  Albus.    Acute  severe  case. 


farther.  Persistent  muscular  spasm  results  in  the  characteristic  mal- 
positions of  the  affection,  flexion,  and  subluxation  of  the  tibia,  and  mus- 
cular spasm  is  an  early  symptom,  perhaps  the  earliest  of  all. 

Malpositions  of  the  limb  result  from  the  greater  power  the  flexor  muscles 
of  the  thigh  possess  in  contrast  to  the  extensors.  The  limb  becomes 
gradually  flexed  almost  from  the  first,  and  if  the  affection  goes  on  -with- 
out treatment,  flexion  may  reach  a  right  angle,  and  this  is  the  tendency 
of  the  disease  throughout  aud  a  marked  obstacle  to  its  successful  treat- 
ment. 

Even  when  the  affection  is  nearly  cured,  the  slightest  imprudence 
on  the  part  of  the  patient  is  likely  to  bring  back  the  flexion,  which  is 
accompanied  by  increased  heat  and  tenderness.      Together  with  the  flexion, 


;i4 


ORTHOPEDIC    SURGERY. 


and  as  a  result  also  of  the  predominance  of  the  flexor  muscles  of  the 
thigh,  subluxation  of  the  tibia  backward  occurs ;   this  is  due  to  the  shape 


Fig.  286.— Radiograph  of  same  Case  as  Fig.  285,  Showing  Indistinctness  of  Lower  End  of  Femur,  where 

Focus  of  Disease  is  Situated. 

of  the  joint  surfaces,   and  the  persistent  contraction  of  the  hamstring 
muscles  always  pulling  the  tibia  backward.     If  the  leg  has  assumed  this 


Fig.  28V.— Subluxation  in  Tumor  Albus. 


distortion  and  is  straightened,  the  tibia  will  lie  in  a  plane  back  Of  that  of 
the  femur,  and  the  part  of  the  knee  formed  by  the  femur  and  patella 
will  be  unduly  prominent. 


TUMOR   ALBUS   OF   THE   KNEE-JOINT. 


315 


Another  result  of  long-continued  muscular  spasm  is  the  external  rota- 
tion of  the  tibia  upon  the  femur,  which  accompanies  severe  grades  of 
flexion  and  persists  after  straight- 
ening of  the  leg  if  such  is  accom- 
plished. In  the  same  way  a  cer- 
tain amount  of  knock-knee  is  apt 
to  be  present  in  the  corrected 
limb  after  severe  grades  of  tumor 
albus. 

Abscess  appears  either  as  a 
purulent  distention  of  the  cap- 
sule, which  may  point  at  any  part 
of  the  surface  and  discharge  by 
sinuses  for  an  indefinite  time,  or 
abscesses  form  in  the  peri-articu- 
lar tissues  as  in  hip  disease.  As 
a  rule  abscess  formation  is  ac- 
companied by  an  acute  degree  of 
the  affection. 

Diagnosis. 

The  diagnostic  symptoms  and 
signs  in  tumor  albus  are  an  inter-  FlG'  288-Position  of  »M* in  Tumor  Albus- 
mittent  lameness ;  a  general  enlargement  of  the  knee-joint,  with  a  feeling 
of  stiffness  and  pain  on  using  the  limb;    heat  over  the  joint;  and  the 


Fig.  289.— Flexion  of  Knee  with  Exter- 
nal Rotation  of  the  Tibia. 


Fig.  290.— Severe  Flexion  of  Knee-joint 
in  Acute  Tumor  Albus. 


316  ORTHOPEDIC    SURGERY. 

presence  of  local  tenderness  and  muscular  stiffness  in  manipulation  of 
the  joint. 

The  character  of  the  enlargement  of  the  knee-joint  is  of  great  impor- 
tance. 

.  Differential  Diagnosis. 

Synovitis. — Gross  errors  in  diagnosis  in  affections  of  the  knee  are  not 
common,  as  a  thorough  examination  of  the  joint  is  readily  made.  The 
distinction  between  a  synovitis  with  effusion  and  a  chronic  ostitis  is  based 
on  the  size  and  shape  of  the  swelling.  A  diagnosis  between  a  subacute 
synovitis  without  effusion  and  an  epiphyseal  ostitis  at  an  early  stage  is 
difficult  or  impossible. 

Practically  it  is  very  often  extremely  hard  to  differentiate  simple 
synovitis  from  a  beginning  tumor  albus,  indeed  it  is  in  many  cases  impos- 
sible to  do.  Sluggish  cases  of  synovitis,  especially  in  young  or  feeble 
persons,  should  be  regarded  with  very  great  suspicion,  inasmuch  as  they 
are  likely  to  eventuate  in  tumor  albus  at  any  time,  if  the  condition  is 
not  already  that. 

Perl-articular  Disease. — Peri-articular  disease  (inflammation  of  bursse, 
and  peri-articular  abscesses)  is  to  be  distinguished  from  true  articular 
disease  in  that  there  is  little  or  no  joint  stiffness,  and  that  the  swelling, 
if  present,  does  not  bear  the  relation  to  the  patella  that  occurs  when 
there  is  fluid  beneath  the  patella;  the  distention  being  clearly  outside 
of  the  joint  sac. 

Functional  disease  (hysterical,  neuromimetic)  of  the  knee  is  to  be 
recognized  by  the  absence  of  objective  symptoms,  and  the  prominence  of 
subjective  symptoms.  Heat  is  generally  absent,  limitation  of  motion  and 
tenderness  may  be  excessive,  and  swelling  and  alteration  of  the  joint 
contour  are  absent. 

Arthritis  deformans  of  the  knee  occurs  as  a  spindle-shaped  enlarge- 
ment of  the  bones,  with  but  little  tenderness  and  a  perceptible  thickening 
of  the  synovial  sac,  with  infiltration  of  the  peri-articular  tissues.  Motion 
is  more  or  less  lost  by  structural  changes,  and  in  irritated  joints  muscular 
spasm  is  present.  A  very  characteristic  sign  is  a  peculiar  creaking  which 
is  felt  with  the  hand  on  the  joint  while  it  is  being  moved.  The  existence 
of  other  signs  of  rheumatoid  arthritis  is  important. 

Rheumatism,  both  acute  and  chronic,  may  simulate  tumor  albus.  In 
certain  cases  a  diagnosis  is  impossible  except  by  aspiration  of  the  joint 
fluid  and  inoculation  into  a  guinea-pig  to  demonstrate  the  presence  or 
absence  of  tuberculosis. 

Haemophilia  may  cause  an  inflammation  of  the  knee  closely  resembling 
tumor  albus.  The  diagnosis  must  be  made  by  establishing  the  existence 
of  the  bleeder's  diathesis. 


TUMOR   ALBUS   OF   THE   KNEE-JOINT.  317 


Prognosis. 

The  prognosis  of  tumor  albus  is  similar  to  that  of  the  same  affections 
of  the  other  large  joints.  The  functional  results  after  conservative  treat- 
ment are  in  average  cases  excellent;  sometimes  perfect  motion  is  restored, 
but  in  general  only  an  incomplete  arc  remains  with  occasionally  complete 
rigidity.  The  earlier  that  treatment  is  begun,  and  the  more  faithfully  it 
is  carried  out,  the  better  is  the  outlook  as  to  functional  result.  In  ad- 
vanced cases  disability  necessarily  follows,  and  in  neglected  cases  de- 
formity of  the  limb,  flexion  at  the  knee,  subluxation  of  the  tibia,  and  the 
formation  and  discharge  of  abscesses  are  likely  to  occur,  ending  either  in 
a  complete  destruction  of  the  joint  or  in  a  cure  with  ankylosis.  A  lia- 
bility of  the  dissemination  of  the  tuberculous  disease  to  the  brain  or  lungs 
exists  in  this  as  in  other  similar  affections. 

In  all  severe  cases  there  is  a  danger  of  permanent  distortion  of  the 
limb.  This  may  be  so  severe  as  to  render  the  limb  useless.  Flexion  of 
the  limb  is  a  constant  result  in  severe  cases  unless  treated  with  great  care. 
Shortening  is  less  likely  to  exist  to  a  troublesome  extent  than  in  hip  dis- 
ease. 

As  in  all  cases  of  epiphyseal  ostitis  of  the  larger  joints,  the  prognosis 
as  to  the  time  of  requisite  treatment  depends  not  only  on  the  time  needed 
to  check  the  inflammation,  but  also  for  the  re-establishment  of  sound 
bone  tissue  capable  of  bearing  weight  without  danger  of  relapse.  This 
in  growing  children  demands  a  long  time.  Protection  is  generally  neces- 
sary for  from  one  to  two  years,  and  perhaps  even  longer,  after  the  acute 
stage  is  ended. 

Treatment. 

The  treatment  may  be  classed  as  conservative  and  operative. 

Conservative  Treatment  of  Tumor  Albus. — What  was  said  in  regard  to 
the  treatment  of  hip  disease  may  be  repeated  in  speaking  of  epiphysitis 
of  the  knee-joint.  The  treatment  should  be  thorough  and  persistent,  and 
should  meet  the  indications,  and  fixation  and  protection  are  the  most  im- 
portant indications  in  diseases  of  the  knee,  while  traction  is  less  so.  The 
employment  of  protection  should  be  continued  until  it  is  probable  that 
the  epiphysis  is  normal,  which  is  a  matter  of  judgment  in  every  case. 
Protection  should  be  discontinued  gradually  and  tentatively ;  if  discon- 
tinued too  soon,  recurrence  will  take  place,  or  the  deformity  of  the  limb 
will  increase.  Fixation  should  be  used  so  long  as  there  is  any  activity  of 
the  inflammation ;  this  is  indicated  by  pain,  muscular  spasm,  or  tender- 
ness. Efficient  fixation  of  the  knee  does  not  requite  confinement  to  bed 
except  in  very  acute  cases,  in  abscess,  and  in  deformity. 

Fixation. — It  is  manifest  that  the  most  thorough  fixation  is  made  if 


318 


ORTHOPEDIC   SURGERY. 


the  fixing  appliance  is  as  long  and  extends  as  high  as  possible.  The  leg 
and  femur,  if  much  longer  than  the  appliance,  will  have  a  greater  me- 
chanical advantage  than  if  the  splints  are  sufficiently  long.  It  should 
also  be  borne  in  mind  that  owing  to  the  fact  that  the  thigh  is  well  covered 
by  soft  tissues  a  certain  amount  of  motion  is  possible  owing  to  the  yield- 
ing of  the  soft  parts.  Fixation  by  stiff  bandages  is  an  efficient  method 
of  treatment  when  the  bandages  are  properly  applied.  They  should  reach 
from  the  groin  to  the  ankle,  and  as  firmly  as  possible  grasp  the  muscles 


FIG.  391.  FIG.  392. 

FIGS.  391  and  393.— Imperfect  Fixation  of  the  Knee  by  Plaster  Bandage. 

of  the  limb.  Plaster-of-Paris  is  the  most  available  material  for  use. 
The  method  does  not  give  in  all  cases  certain,  definite  support.  Judson 
says  in  regard  to  it :  "  It  may  be  an  exaggeration,  but  it  conveys  the 
idea,  to  say  that  a  plaster-of-Paris  or  silicate  splint,  applied  to  the  leg 
and  thigh,  contains  a  mass  of  jelly  in  which  the  femur  is  but  little  re- 
strained from  motion,"  and  in  a  degree  this  is  true  of  all  stiff  bandages. 

The  figure  shows  the  inefficiency  of  a  loosely  applied  plaster  bandage 
so  far  as  fixation  is  concerned.  Other  stiff  bandages  are  of  silicate  of 
potash,  leather,  celluloid,  wood  pulp,  papier  mache,  etc.  They  may  be 
cut  down  the  front  and  laced  so  as  to  be  removed  at  any  time.  Fixation 
without  protection  is  inadequate  treatment  when  locomotion  is  desired. 
For  this  reason  it  is  insufficient  to  apply  a  stiff  splint  to  the  affected  leg 
and  to  allow  the  patient  to  walk  without  further  protection  of  the  limb. 


TUMOR   ALBUS   OF   THE   KNEE-JOINT. 


319 


Fixation  as  a  means  of  treatment  so  far  has  been  considered  only  as 
applicable  to  the  limb  in  its  straight  position.  Much  more  often  a  degree 
of  flexion  is  present  to  complicate  matters,  the  treatment  of  which  will 
be  considered  later. 

Protection. — Protection  can  be  furnished  by  means  of  crutches,  and 
raising  the  sound  limb  by  a  thick  sole  which  allows  the  affected  limb  to 


Fig.  293.— Thomas' Knee  Splint  for  Right  Leg. 
yi,  Perineal  ring ;  C,  foot  piece ;  D,  leather 
lacings  ;  E,  straps  to  go  over  shoulder. 


Fig.  394.— Thomas'  Knee  Splint.    (Children's 
Hospital  Report.) 


swing  clear  of  the  ground.  Better  protection  is  furnished  by  means  of  a 
splint  with  perineal  support  and  longer  than  the  limb,  which  passes 
below  the  foot  so  as  to  take  the  jar  of  locomotion.  The  best  of  these 
splints  is  one  similar  to  that  already  described  as  a  protective  splint  in 
hip  disease.  It  will  be  described  more  fully  in  speaking  of  the  treat- 
ment of  flexion  in  tumor  albus. 

A  simple  appliance  is  the  Thomas  knee  splint,  which  consists  of  a 


320 


ORTHOPEDIC   SURGERY. 


padded  iron  ring  fitted  so  as  to  surround  the  thigh  at  the  perineum,  and 
fastened  to  two  rods  on  each  side  of  the  limb,  longer  than  the  limb  and 
secured  at  the  bottom  to  a  metal  plate  below  the  foot  or  bent  to  fit  into  a 
slot  under  the  shank  of  the  boot.  The  thigh  ring  is  placed  at  an  angle 
of  55°  to  the  uprights,  which  angle  is  reduced  by  the  padding  of  the  ring 
to  45°.      The  inside  upright  extends  from  the  perineum  to  three  inches 


Fig.   295.— Fixation    Ap- 
pliance  for   Thomas'  Knee       Fig.  296.— Thomas'  Knee  Splint  Applied.    (Chil- 
Splint.  dren's  Hospital  Report.) 


Aw 

Fig.  297.— Appli- 
ance for  Adjusting 
the  Length  of  the 
Thomas  Knee 
Splint.    CBurrell.) 


below  the  sole  of  the  foot.  When  the  ring  at  the  bottom  is  used  the  out- 
side upright  extends  from  half-way  between  the  crest  of  the  ilium  and 
the  top  of  the  great  trochanter  to  three  inches  below  the  sole  of  the  foot. 
In  measuring  for  the  splint  the  circumference  of  the  thigh  at  the  groin 
should  be  measured  and  allowance  made  for  padding  the  ring.  The 
length  of  the  uprights  and  the  places  on  the  ring  where  the  uprights 
should  be  attached  should  be  measured.  These  uprights  should  be  so 
placed  as  to  be  in  the  same  plane  as  the  shaft  of  the  femur. 

The  bar  at  the  bottom  of  the  splint  can  be  utilized  as  a  means  for 
using  traction  if  adhesive  plaster  is  applied  to  the  leg  and  webbing  sewn 


TUMOK    A.LBUS    OK    TIIK    KNEE-JOINT. 


321 


to  the  lower  ends;  the  webbing  straps  are  buckled  tightly  around  the  bar, 
and  a  certain  amount  of  traction  can  be  exerted.  The  idea  of  using  trac- 
tion is  not  in  accordance  with  the  views  of  the  inventor  of  the  splint. 
The  leg  can  be  fixed  by  means  of  bandages  which  pass  around  the  leg  and 
splint  or  by  means  of  leather  bands  attached  to  the  splint  and  lacing 
around  the  leg.      With  this  splint  applied,  the  patient  sits  in  a  ring  sup- 


atwgpmNN 


Fig.  298. 
Figs.  298  and  299.— Thomas'  Knee  Splint  with  Leather  Lacings. 

Hospital  Report). 


Fig.  299. 
Part  of  ring  cut  away.    (Children's 


porting  the  perineum,  while  uprights  run  below  the  foot  and  bear  the  body 
weight.  The  protected  limb  can  then  be  fixed  by  means  of  the  bandages 
or  leather  lacings  just  spoken  of. 

In  cases  requiring  less  rigid  protection  and  in  the  case  of  adults  the 
inner  half  of  the  perineal  ring  is  cut  away  and  from  the  two  extremities 
of  the  cut  ring  is  slung  a  leather  perineal  band  on  which  the  patient  rests 
in  the  same  manner  as  in  a  hip  splint.  In  very  acute  cases  a  stiff  band- 
age to  the  knee  in  addition  to  the  Thomas  splint  contributes  better  fixa- 
tion than  is  possible  with  the  splint  alone. 

For  convenience  it  is  often  desirable  to  change  the  length  of  the  splint, 
21 


322 


( )R THOPKDIC    SURGERY . 


and  this  can  be  done  by  the  addition  of  a  simple  arrangement  devised  by 
Burrell.  The  uprights  are  made  of  two  parts,  the  upper  one  passes  in 
the  lower,  which  is  a  hollow  rod;  a  thread  is  cut  in  the  upper  rod  and  a 
nut  screwed  on  it;  by  setting  the  nut  at  a  higher  or  lower  point,  the  up- 
right is  practically  lengthened  or  shortened,  while  the  inner  rod  is  pre- 
vented from  dropping  out  of  the  outer  hollow  rod  by  means  of  a  screw 

which  passing  through  the  outer  rod 
catches  the  inner  rod  and  holds  it 
firmly.  The  diagram  shows  the  con- 
struction of  the  appliance  (Fig.  297). 
The  Thomas  splint  is  slung  from 
the  shoulder  by  means  of  a  strap, 
and  the  well  limb  is  raised  by  means 
of  a  cork,  wooden,  or  steel  patten. 
Crutches  are  not  generally  neces- 
sary in  connection  with  the  Thomas 
splint. 

When  the  condition  of  the  limb 
has  improved  so  much  that  pain  and 
sensitiveness  are  absent  or  in  mild 
cases  the  Thomas  splint  can  be 
shortened,  and  the  ends  slotted  into 
the  sole  of  the  shoe  at  such  a  place 
that  the  splint  is  too  long  for  the 
heel  to  touch  the  ground,  and  in 
this  way  the  patient  walks  about 
suspended  largely  by  the  perineal 
ring  and  bearing  but  little  weight  on 
the  diseased  joint.  Then  gradually 
after  some  months  the  use  of  the 
splint  may  be  discontinued. 

Slight  cauterization,  blisters,  and 
iodine  may  be  of  assistance  in  the 
slighter  cases;  but  in  severer  forms 
of  epiphyseal  ostitis  more  radical 
measures  are  needed.  The  introduction  of  the  actual  cautery  into  the 
bone  tissues  softened  by  ostitis  has  seemed  to  the  writers  to  have  a  bene- 
ficial effect  in  some  cases  in  stimulating  the  development  of  a  cicatricial 
granulating  tissue,  but  only  in  connection  with  mechanical  treatment. 
Subcutaneous  and  intra-articular  injections  have  not  in  the  writers'  hands 
proved  of  much  benefit. 

Treatment  of  Complications. — Flexion  of  the  knee  is  the  most  common 
and  the  most  troublesome  complication  of  tumor  albus.  It  is  usually  as- 
sociated, when  it  occurs,  in  the  early  part  of  the  disease  with  an  acutely 


Fig.  300.— Thomas'  Splint  with  Inner  Part  of 
Ring  Cut  Away,  fitted  as  a  Convalescent  Splint. 
(Children's  Hospital  Report.) 


TUMOR   ALBUS   OF   THE    KNEE-JOINT.  323 

sensitive  condition  of  the  joint,  but  later  in  the  history  it  may  come  on 
insidiously  and  without  pain. 

The  means  of  straightening  a  knee-joint  flexed  by  acute  disease  may 
be  classified  as  follows : 

1.  By  traction  in  the  line  of  the  deformity  applied  (a)  in  bed;  (b) 
while  the  patient  goes  about. 

2.  By  means  of  apparatus  forcibly  straightening  the  leg;  such  as  the 
Billroth  splint,  the  Thomas  knee  splint,  etc. 

3.  By  simple  fixation  by  means  of  a  succession  of  plaster-oi'-Paris 
bandages. 

4.  By  straightening  under  ether. 

1  (a).  In  sensitive  cases  it  may  be  necessary  to  confine  the  patient  to 
bed.  Traction  by  weight  and  pulley  can  be  applied  to  the  leg  by  means 
of  adhesive  plaster  applied  below  the  knee,  the  leg  being  supported  by 
a  firm  cushion  under  the  knee  arranged  so  that  traction  comes  in  the  line 
of  the  deformity.  After  a  diminution  of  the  spasm,  which  follows  very 
soon  upon  the  application  of  traction,  the  limb  can  be  made  straight 
gradually  and  fixed  in  a  straightened  position,  and  ambulatory  treatment 
can  be  begun. 

1  (b).  Traction  in  the  line  of  the  deformity  can  be  applied  to  the  limb 
while  the  patient  goes  about,  by  one  of  several  appliances  which  are  more 
or  less  expensive.  The  best  splint  is  one  already  alluded  to,  similar  to 
the  protection  splint  described  for  hip  disease. '  It  is  furnished  with  a 
perineal  band  which  takes  the  body  weight  off  of  the  leg,  and  at  the  knee 
is  a  lock  joint  which  can  be  set  at  any  angle.  The  bottom  of  the  splint 
goes  far  enough  below  the  foot  to  protect  the  limb  from  jar  in  walking, 
and  ends  in  a  traction  bar.  The  splint  is  set  at  an  angle  corresponding 
to  the  angular  deformity  of  the  jfflfected  knee,  and  traction  is  made  up- 
ward above  the  knee  by  means  of  adhesive  plaster  attached  to  the  thigh 
and  buckling  on  to  the  splint,  and  extension  is  made  downward  below  the 
knee  by  a  plaster  extension  pulling  down  to  the  traction  bar  at  the  bottom 
of  the  splint.  The  leg  is  fixed  in  the  splint  by  leather  lacings  for  the 
thighs  and  calf,  which  are  adjusted  after  the  extension  is  tightened.  A 
simpler  apparatus  has  been  described  by  H.  L.  Taylor,2  made  of  plaster- 
of-Paris  and  serving  the  same  purpose  except  that  it  does  not  allow 
weight  bearing  on  the  affected  leg. 

2.  Correction  by  Means  of  Apparatus  Forcibly  Straightening  the  Leg. 
— The  Billroth  splint  is  an  efficient  means  of  overcoming  the  deformity 
•in  cases  in  which  the  patients  can  be  kept  under  observation.  A  plaster 
bandage  is  applied  to  the  limb  in  which  are  incorporated  two  jointed  iron 
strips  attached  to  broad  plates.  The  bandage  is  allowed  to  harden  and 
then  the  front  over  the  knee  is  cut  out  and  at  the  back  where  it  has  been 


1  Lovett :  Orth.  Trans.,  vol.  vi.         *  H.  L.  Taylor :  Orth.  Trans.,  vol.  vii.,  p.  53. 


324 


ORTHOPEDIC    SURGERY. 


purposely  made  quite  solid,  a  transverse  division  of  the  plaster  is  made. 
Into  this  slit  are  inserted  wedges  of  increasing  size  until  the  leg  is 
straight.  The  splint  has  to  be  watched  or  it  will  cause  sloughs,  as  it 
exerts  considerable  pressure. 

The  Thomas  knee  splint  can  be  used  to  correct  deformity ;  the  band- 
age being  applied  in  front  of  the  thigh  and  the  knee  and  behind  the 
calf.  By  tightening  them,  the  limb  can  be  forced 
«-».  into  a  corrected  position.  This  is  the  method  ad- 
vocated by  Mr.  Thomas,  but  in  the  hands  of  the 
writers  it  has  in  many  cases  at  once  started  an 
acutely  sensitive  condition  of  the  joint.  For  this 
reason,  the  appliance  should  be  used  with  great 
care  as,  if  injudicious  force  is  used,  an  acute  stage 
of  arthritis  can  be  readily  brought  about.  With 
proper  and  skilful  adjustment  of  the  bandage,  proper 
pressure  on  the  back  of  the  tibia  can  be  exercised; 
but  if  too  great  pressure  is  exerted  on  the  lower 
part  of  the  leg,  and  too  little  on  the  tibia,  the  head 
of  the  tibia  may  be  crowded  against  the  end  of  the 
femur  and  the  ostitis  increased. 

A  simple  wire  splint  is  useful  in  correction  of 
this  deformity  in  the  class  of 
cases  in  which  the  sensitiveness 
is  not  great.  It  consists  of  a 
wire  splint  to  which  the  thigh 
is  attached;  the  leg  is  pulled 
upon  especially  behind  the 
head  of  the  tibia,  thereby 
avoiding  the  uncomfortable  re- 
sults of  exerting  the  straight- 
ening force  wholly  from  the 
lower  part  of  the  leg. 

3.  Reduction  of  Flexion  by 
Fixation    Bandages.  — A    very 
simple    way    to    straighten    a 
knee-joint    acutely    flexed    by 
disease,    when   apparatus  can- 
not be  afforded  or  is  impracti- 
cable, is  by  simple  fixation  of 
the   knee-joint  by  means  of  a 
series  of  plaster-of-Paris  bandages.     These   should    be   applied   to   the 
knee  in  its  deformed  position  without  any  attempt  to  extend  it.      It  will 
be  often  found  in  the  lighter  cases  that  the  limb  can  be  made  straighter 
at  each  successive  bandage,  so  great  is  the  sedative  action  of  complete 


H 


Fig.  301.  —  Splint  lor 
Traction  on  Knee  at  any 
Angle. 


Fig.  302.— Billroth's 

Splint    lor    Straightening 
the  Knee. 


TUMOR    ALU  US    OF    THE    KNKK-.JOIXT. 


325 


fixation.      It  is  hardly  necessary  to  add  that  no  weight  should  he  home 
upon  the  limb  during  the  process  of  straightening. 

4.  Forcible  Reduction  of  Flexion. — With  regard  to  the  straightening 
of  the  knee  in  acute  cases  under  an  anaesthetic  it  is  not  a  measure  to  he 
adopted  unless  it  is  impossible  to  afford  time  for  gradual  straightening 
either  in  bed  or  while  the  patient  goes  about.  Pain  is  generally  occa- 
sioned by  the  proceeding,  which  is  often  the  cause  of  an  exacerbation  of 
the  disease.  In  cases  without  adhesions  the  knee  is  easily  put  in  a  cor- 
rect position  with  the  use  of  little  or  no  force  under  complete  anaesthesia. 


Fig.  303.— Wire  Splint  for  Gradual  Correction  of  Knee  Flexion. 


If  the  leg  is  allowed  to  remain  in  the  flexed  position,  angular  ankylosis 
will  probably  occur  as  shown  in  the  figures.  When  firm  adhesions  have 
been  formed  at  the  knee-joint,  correction  by  means  of  appliances  will  be 
found  tedious,  painful,  and  sometimes  impossible,  and  generally  forcible 
correction  of  some  sort  will  be  necessary  to  break  down  the  adhesions. 
One  way  is  to  break  down  the  adhesions  by  forcibly  flexing  the  leg,  and 
then  by  forcible  extension  to  straighten  it.  The  danger  of  rupturing  the 
popliteal  artery,  which  has  occurred,  is  in  this  way  diminished.  Many 
appliances  have  been  devised  to  give  greater  power  in  forcible  correction. 
One  procedure  not  requiring  the  use  of  apparatus  is  as  follows :  The 
patient  is  placed  upon  the  floor  upon  the  back  and  the  surgeon  stands 
over  the  patient  holding  the  flexed  knee  with  both  hands,  the  fingers 
being  placed  under  the  popliteal  space.     The  whole  weight  of  the  sur- 


326 


ORTHOPEDIC   SURGERY. 


geon's  trunk  can  be  thrown  upon  the  end  of  the  lever  furnished  by  the 
patient's  leg,  the  hands  of  the  surgeon,  pulling  upon  the  popliteal  space, 
furnishing  resistance.  After  the  limb  has  yielded  and  the  adhesions  are 
broken,  it  can  be  straightened  if  the  patient  is  turned  upon  the  face ;  a 
downward  force  being  applied  to  the  heel,  resistance  being  furnished  by 
a  cushion  placed  under  the  patient's  knee.  When  subluxation  of  the 
tibia  is  present  it  must  be  corrected.  This  cannot  be  done  so  well  by 
this  method  as  by  the  instrumental  method  to  be  described.  After  cor- 
rection, the  limb  should  be  well  surrounded  with  sheet  wadding  and  a 


Fk;.  304-.— Pendulum  Appliance  for  Straightening  the  Knee.     The  pendulum  1J  is  adjustable  at  the  socket 
< ',  where  the  balanced  bar  B  plays  on  A ,  attached  to  a  stool. 


stiff  bandage  applied,  the  limb  being  held  straight  until  the  plaster  has 
become  hard.  The  procedure  is  sometimes  followed  by  pain,  and  opiates 
may  be  necessary  for  a  few  days.  Such  measures  are  not  required  except 
in  resistant  cases.  The  dangers  incurred  by  this  procedure  are  not  so 
great  as  would  be  supposed.  The  danger  of  rupture  of  the  artery  can 
be  avoided  by  care.  Separation  of  the  epiphysis  of  the  femur  may  take 
place,  but  is  cured  by  the  fixation  requisite  to  treatment,  and  should  not 
occur  if  the  force  is  carefully  applied.  Fracture  of  the  femur  and  tibia 
can  be  avoided  by  care. 

If  the  deformity,  flexion,  remains  uncorrected  in  severe  ostitis  of  the 
knee-joint,  a  subluxation  of  the  tibia  backward  takes  place,  due  to  the 
contraction  of  the  ham-string  muscles.     This  is  due  in  part  to  the  spasm 


TUMOR   AIJ3US    OF    THE    KNEE-JOINT. 


327 


of  the  ham-string  muscles,  which  have  pulled  the  tibia  backward,  but 
chiefly  to  the  fact  that  owing  to  adhesions  the  flexed  tibia  is  unable  to 
slide  forward  over  the  condyles  of  the  femur,  as  happens  in  normal  ex- 
tension. Attempts  to  straighten  the  leg  simply  crowd  the  anterior  edge 
of  the  tibia  into  the 
condyles.  To  obviate 
this  the  head  of  the 
tibia  should  be  pressed 
forward  and  upward  to 
the  same  degree  that 
the  leg  is  raised. 

The  most  efficient 
method  of  accomplish- 
ing this  is  by  the  use 
of  the  apparatus  shown 
in  the  figure  called  by 
Goldthwait, '  who  modi- 
fied it  from  the  original 
apparatus,  the  "  genu- 
clast." 

Pressure  forward  on  the  head  of  the 
tibia  is  exerted  by  turning  the  handle,  this, 
by  means  of  a  screw  force,  pushes  a  plate 
forward  against  the  tibia,  working  through  a 
band.  The  calf  muscles  protect  the  artery 
and  nerve  from  injurious  pressure.  Counter- 
pressure  is  secured  by  means  of  leather 
straps,  which  are  passed  respectively  over 
the  knee  and  leg,  protected  by  a  thick  layer 
of  saddler's  felt.  Several  straps  will  be 
needed  at  the  knee  to  prevent  loss  of  counter- 
pressure,  as  the  limb  is  made  straighter. 
Another  strap,  under  the  leg,  secures  the 
lower  part  of  the  leg.  The  side  bars,  bands, 
and  plate  of  the  apparatus  should  be  of 
strong  steel. 

The  apparatus  is  put  on  the  limb  in  a  flexed  position  (after  rupturing 
adhesions  by  forcible  flexion  if  that  is  needed),  the  head  of  the  tibia  is 
pushed  forward  as  far  as  is  advisable,  and,  by  means  of  the  end  of  the 
appliance,  which  serves  as  a  handle,  the  leg  is  extended;  the  pressure 
forward  of  the  head  of  the  tibia  can  be  increased,  and  the  counter- 
pressure  regulated  if  necessary,  by  loosening  such  of  the  straps  as  exten- 


Fig.  305.— Goldthwait "s  Genuclast. 


'  Boston  Med.  and  Surg.  Jour.,  September  7th,  189:!. 


328  ORTHOPEDIC   SURGERY. 

sion  of  the  limb  may  tighten  too  much.  In  some  cases  the  reduction  may 
be  accomplished  at  one  time,  while  in  others  successive  applications  of  the 
apparatus  are  necessary.  Adhesions  of  the  patella  to  the  front  of  the 
femur  may  constitute  an  obstacle  to  reduction  without  cutting.  The 
treatment  of  cases  resisting  this  method  will  be  considered  in  the  section 
of  this  chapter  on  operative  treatment. 

Experiments  on  the  cadaver  which  were  conducted  by  one  of  the 
writers  at  the  Harvard  Medical  School,  through  the  courtesy  of  Drs.  C. 
B.  Porter  and  T.  Dwight,  showed  that  by  means  of  this  appliance  the 
tibia  could  readily  be  pushed  forward  to  any  desired  extent.  On  normal 
joints,  the  tibia  can  be  pushed  forward  to  a  considerable  distance  without 
rupturing  the  ligaments. 

In  general  correction  of  flexion  deformity  under  ether  is  the  best 
method  except  in  slight  cases. ' 

Abscess.- — The  treatment  of  peri-articular  abscess  is  the  same  that  is 
recommended  for  the  treatment  of  abscess  at  the  hip.  They  are  gener- 
ally superficial  and  do  not  dissect  about  between  the  muscles  to  the 
extent  that  hip  abscesses  often  do. 

Operative   Treatment  of  Tumor  Albas 
The  operative  measures  to  be  considered  are : 

(1)  Excision. 

(2)  Arthrectomy. 

(3)  Amputation  of  the  leg. 

(1)  Excision  of  the  knee-joint  is  to  be  undertaken  in  those  cases  in  which 
conservative  treatment  has  failed  to  arrest  the  progress  of  the  disease; 
in  which  originally  the  disease  is  too  extensive  to  warrant  conservative 
treatment;  in  which  the  general  health  is  failing  and  the  disease  failing  to 
improve  under  efficient  conservative  measures.  In  adults  it  is  to  be  un- 
dertaken earlier  than  in  children,  as  the  progress  of  the  disease  is  in  the 
former  less  favorable  than  in  the  latter. 

Excision  is  inferior  to  conservatism  as  a  treatment  of  knee-joint  disease, 
because  the  mortality  rate  is  higher  and  the  functional  results  are  not  so 
good. 

Excision  of  the  knee  is  also  performed  to  correct  the  deformity  caused 
by  bony  ankylosis  at  an  angle  of  flexion. 

Mortality. — Lossen,2  analyzing  580  cases  of  knee-joint  resection  done 
for  tuberculosis  or  its  resulting  deformity,"  found  the  results  to  lie  as  fol- 

1  Report  City  Hospital,  Boston,  fourth  series;  Bull,  et  Mem.  de  la  Societe  de 
Chir.,  vol.  v.,  p.  461. 

-Lossen:  Deutsch.  Chir..  Leipsic.  Bd.  2!L 

sffitzgerad:  Cent.  f.  Chir..  1888,  49,  p.  (.>l!>;  Heinke:  Inaug.  Diss.,  Bonn,  1888; 
Neugebauer:  Deutsch.  Zeit.  f.  Chir.,  xxix.,  1889,  p.  379;  v.  Zeuge  Mauteuffel ■:  Ibid., 
xxix..  1889,  p.  113;  Schliiter:  Ibid.,  xxx..  1890,  p.  285;  Bothe :  Beitrage  zu'r  klin. 
Chir.,  Bd.  vi.,  l^'.K).  p.  i>53 ;  Krenz:  Inaug.  Diss..  Wiirzburg.  1891. 


TUMOR  ALBUW  OF  THE  KNEE-JOINT. 


329 


lows:  439  (74.9  per  cent)  healed;  59  (10.1  percent)  unhealed;  50  (8.5 
per  cent)  amputated;  .">8  (6.5  per  cent;  died. 

In  384  cases  in  which  the  end  results  could  )>e  traced  one  to  fourteen 
years  after  operation  the  results  were  as  follows:  274  (71.3  per  cent) 
remained  healed ;  46  (12  per  cent)  still  had  fistulous  openings;  18  (4.7 
per  cent)  were  unhealed;  10  (2.6  per  cent)  were  amputated;  36  (9.4  per 
cent)  died. 

In  o2i)  cases  tabulated  by  Phelps1  in  which  the  operation  was  done 
antiseptically  there  were  31  deaths  (9.4  per  cent),  practically  the  same 
as  in  Lossen's  group.     Considered  by  age  the  results  were  as  follows. 


Under  5  years, 

From 

5  to  10 

years, 

10  " 

15 

a 

15  " 

20 

u 

20  " 

25 

" 

25  " 

30 

a 

30  " 

40 

a 

Over  40  years, 

The  average  of  all  being, 


Mortality. 
38.9  per  cent. 
16.2  " 
17.2  '• 
30.1  " 
3D. 4  " 
37.<)       " 

41.5  " 

52.6  " 


29.8 


It  would  lie  fair  to  assert  that  in  patients  between  five  and  twenty, 
the  mortality  from  the  operation,  near  and  remote,  would  not  be  far  from 
ten  per  cent,  being  less  rather  than  more  than  this  percentage. 

Statistics  in  regard  to  the  ultimate  results  of  conservative  treatment 
of  disease  of  the  knee  are  unfortunately  of  little  value  as  a  guide  in  -the 
consideration  of  proper  treatment  of  disease  of  the  knee-joint;  it  may  be 
said,  however,  that  conservative  treatment  in  children  gives  most  excel- 
lent results  in  cases  which  can  be  watched 2  and  treated  for  a  long  time. 

The  functional  results  after  excision  are,  however,  decidedly  inferior 
to  the  results  after  conservative  treatment.  Ankylosis  is  to  be  hoped  for 
after  excision  and  is  complicated  by  a  tendency  to  flexion  of  the  appar- 
ently ankylosed  joint.  In  130  cases  analyzed  by  Hoffa  there  were  14 
cases  of  slight  flexion  and  30  cases  of  severe  flexion  noted  when  the  end 
results  were  considered.  This  of  course  is  a  very  serious  matter  and 
should  make  the  surgeon  very  careful  about  removing  splints  before  there 
is  reason  to  believe  that  firm  bony  ankylosis  is  present.  This  generally 
occurs  after  apparent  union  has  taken  place  and  the  patient  has  been  dis- 
charged from  immediate  supervision. 


•Trans.  N.  Y.  State  Med.  Soc,  1880,  p.  586. 

-  Centre Jblatt   f.   Chirurgie,  No.  49,  December  8th,  188o  ;    Deutsche   Zeitschr.  f. 
Cbir.,  1885,  Bel.  21,  Heft  4. 


330  ORTHOPEDIC    SURGERY. 

It  may  be  said  with  regard  to  the  amount  of  shortening  after  excision 
in  cases  in  which  the  epiphyseal  lines  are  saved  that  it  is  likely  to  be  only 
moderate,  although  even  then  it  is  more  than  after  conservative  treat- 
ment. In  the  cases  of  Hoffa'  in  which  both  epiphyseal  lines  had  been  re- 
moved by  operation,  the  shortening  was  extreme,  e.g.,  8  inches  in  10 
years,  3  inches  in  2  years,  etc.  When  only  one  line  is  removed  and  the 
one  in  the  other  bone  left,  there  is  shortening,  but  less;  5  inches  in  6 
years,  2  inches  in  1  .V  years,  etc.  When  both  epiphyseal  lines  were  saved 
the  cases  showed  much  less  tendency  to  progressive  shortening;  inside  of 
2  years  after  operation  it  never  exceeded  If  inches,  and  in  the  worst  ease 
of  all  it  was  only  4  inches  and  a  fraction  after  6  years,  while  many  older 
cases  showed  less  shortening. 

It  would  not  be  fair,  however,  to  dismiss  the  subject  without  adding 
that  severe  tumor  albus  without  resection  may  cause  serious  arrest  of 
growth  in  the  bones  in  cases  which  heal.  Nine  such  cases  are  reported 
by  Caumont  in  which  it  ranged  from  ^  of  an  inch  to  4  inches.  The  short- 
ening after  extensive  excision  is  far  greater  in  general  than  after  a  spon- 
taneous cure.  Konig's  rule  is  most  valuable  in  this  regard:  "  Saw  off 
inside  the  extent  of  the  cartilage." 

The  operation  of  excision  of  the  knee-joint  is  performed  as  follows : 

The  leg  should  be  carefully  prepared  for  an  aseptic  operation.  The 
use  of  the  Esmarch  bandage  and  tourniquet  is  advisable.  The  joint  is 
opened  by  one  of  the  anterior  incisions  in  common  use,  the  periosteum  and 
muscular  attachments  are  cleared  from  the  ends  of  the  bones,  the  ligaments 
are  cut,  and  the  articular  end  of  the  femur  protruded  through  the  incision 
and  as  much  as  seems  desirable  sawed  off.  In  the  same  way  the  tibia  is 
cleared  and  protruded  as  a  safeguard  against  injuring  the  popliteal  vessels. 
It  is  well  not  to  saw  quite  through  to  the  posterior  aspect  of  the  bones, 
but  to  saw  nearly  through  and  then  to  break  off  the  slice  with  a  perios- 
teum elevator. 

The  femur  may  be  dovetailed  into  the  tibia  by  cutting  a  concavity  in 
the  tibia  with  a  butcher's  saw  and  cutting  the  femur  to  fit  into  it.  It  is 
not  an  easy  matter  to  do  this  and  it  adds  much  to  the  difficulty  of  the 
operation.  In  any  case  the  patella  should  be  removed  if  it  is  diseased, 
or  if  it  has  been  divided  in  the  operation  the  halves  should  be  sewed  to- 
gether with  silver  wire  or  catgut.  As  to  drainage,  there  is  no  need  of 
the  posterior  counter-opening  made  by  some  surgeons,  for  drainage  is 
perfectly  good  if  the  incision  begins  far  enough  back  on  the  leg. 

It  is  impossible  to  say  how  thick  a  section  should  be  removed  from 
the  ends  of  the  bones.  In  adults  it  matters  not  whether  the  section  goes 
beyond  the  epiphysis  so  long  as  all  the  diseased  tissue  is  removed.  In 
children  only  very  exceptionally  is  one  justified  in  crossing  the  epiphy- 


1  Arch.  f.  klin.  Chir..  1885,  iv..  32. 


TUMOR    ALBUS    OF   THE    KNEE-JOINT.  333 

seal  line.  It  is  best  at  first  to  remove  a  very  thin  section,  just  enough  to 
take  all  the  articular  surface  of  both  bones,  and  then  to  remove  another 
section  if  the  disease  is  very  extensive,  or  if  only  foci  of  disease  are  seen 
to  scoop  them  out  extensively  with  a  sharp  spoon. ' 

It  is  of  the  utmost  importance  to  attend  carefully  to  the  plane  of  sec- 
tion which  the  saw  makes  in  removing  the  articular  surfaces.  If  these 
planes  are  ever  so  slightly  oblique  the  whole  axis  of  the  limb  is  distorted 
and  the  line  of  weight-bearing  is  wrong  and  tends  to  cause  angular  de- 
formity at 'the  knee.  In  the  femur  the  plane  of  section  should  be  parallel 
to  the  articular  surface  and  not  perpendicular  to  the  shaft  of  the  bone, 
which  would  make  it  oblique  at  the  joint.  As  soon  as  section  of  the 
bones  has  been  made,  the  new  surfaces  should  be  placed  in  contact  and 
the  line  of  the  limb  carefully  observed. 

To  secure  fixation  the  bones  may  be  wired  together  or  fastened  to  each 
other  by  nails  or  pegs  of  ivory  or  bone.  Any  of  these  methods  are  likely 
at  any  time  to  prove  unsatisfactory  ;  but  at  times  they  will  be  found  to  be 
of  assistance.  Another  method  is  to  fix  the  limb  without  the  use  of  nails 
or  wire.  A  wire  posterior  splint  may  be  used.  In  general,  plaster  of 
Paris  forms  the  most  satisfactory  splint  put  on  over  a  heavy  antiseptic 
dressing,  the  bones  having  been  fixed  accurately  in  position  by  some  of 
the  means  mentioned  and  the  limb  after  that  handled  very  carefully. 
The  only  objection  to  it  is  that  in  the.  profuse  discharge  of  serum  which 
takes  place  necessarily  from  so  large  a  wound  within  the  first  twenty -four 
hours,  the  plaster  is  likely  to  be  stained  through  and  may  have  to  be 
changed.  But  if  a  sufficiently  heavy  dressing  is  put  on,  this  will  ordina- 
rily not  happen  to  any  extent,  or  if  it  does  a  light  dressing  can  be  applied 
outside  to  protect  the  stained  spot.  Occasionally  the  plan  is  useful  to 
dress  the  limb  after  operation  in  a  heavy  dressing  and  on  the  next  day  to 
redress  it  and  apply  the  plaster.2  In  this  way  one  may  be  almost  sure 
of  a  dressing  which  can  be  left  on  almost  indefinitely,  provided  the 
operation  has  been  aseptic. 

There  are  two  precautions  to  be  observed  in  putting  the  leg  up  in 
splints  or  in  plaster ;  first,  the  tendency  to  eversion,  and  second,  the  ten- 
dency to  dropping  backward  of  the  head  of  the  tibia.  With  moderate 
precautions  these  deformities  may  be  avoided.  When  the  bones  are  wired 
together,  if  the  holes  which  are  bored  in  the  tibia  for  the  insertion  of  the 
wire  are  placed  well  backward  and  the  corresponding  holes  in  the  femur 
well  forward,  much  will  be  done  to  counteract  this  backward  displace- 
ment of  the  leg  upon  the  thigh. 

The  late  after-treatment  of  excision  requires  no  comment.  The  only 
danger  that  exists  is  that  weight  may  be  borne  upon  the  limb  too  soon, 
before  firm  bony  ankylosis  may  have  occurred.      It  is  much  the  wiser 

'Cent.  f.  Chir.,  1887.  p.  440.  2Brit.  Med.  Journ..  April  2d.  1887. 


S:i2 


ORTHOPEDIC    SURGERY 


course  to  have  the  patient  wear  a  perineal  crutch  (in  the  form  of  a 
Thomas  knee-splint)  which  shall  prevent  bearing  any  weight  on  the  leg 
until  several  months  after  operation.  If  this  precaution  is  neglected, 
permanent  flexion  of  the  limb  is  likely  to  occur  or  a  lighting  up  of  the 
original  disease. 

Excision  of  the  Knee  for  Angular  Ankylosis. — -When  excision   of   the 
knee  is  done  for  angular  ankylosis,  the  only  modification  of  the  operation 


Fk;.  3(C. 


Fig.  306.— Angular  Ankylosis  of  Knee. 


-Osteotomy  for  Deformity  with  Anky- 
losis.    (After  Hoffa.  I 


which  is  necessary  is  the  removal  of  a  wedge  of  bone  large  enough  to 
allow  the  ends  of  the  bone  to  come  together,  so  that  the  angularity  is 
obliterated. 

The  knee  is  exposed  as  for  simple  excision,  except  that  a  more  exten- 
sive flap  is  made,  and  then  a  wedge  of  bone  is  sawed  out,  of  the  required 
size  to  allow  the  knee  to  be  straightened.  The  after-treatment  is  the 
same  as  in  an  ordinary  excision.  A  simple  method  suffices  to  show  the 
size  of  the  base  of  the  wedge  to  be  removed.  If  the  leg  is  laid  on  the 
side  previous  to  operation  and  traced  in  outline  on  a  large  sheet  of  paper 
and  the  tracing  of  the  leg  is  cut  out,  a  wedge  of  the  paper  may  be  re- 
moved from  the  cut-out  piece  where  the  angle  occurs.  The  removal  of 
this  piece,  if  it  is  of  proper  size,  allows  the  paper  leg  to  be  straightened. 


TUMOR   ALBLJS   OP   THE   KNEE-JOINT.  666 

A  paper  wedge  of  the  proper  size  shows  the  size  of  the  wedge  of  bone 
which  must  be  removed  to  straighten  the  leg. 

Supracondyloid  osteotomy  of  the  femur  is  also  to  be  mentioned  as  a 
means  of  correction  in  angular  deformity  of  the  knee,  especially  when 
the  ankylosis  is  not  complete,  yet  when  correction  cannot  be  obtained  by 
non-operative  measures.  The  advantage  of  this  method  lies  in  the  fact 
that  any  motion  remaining  at  the  joint  is  not  destroyed  as  it  must  be  in 
excision.  Its  disadvantage  is  that  the  condyles  of  the  femur  are  neces- 
sarily displaced  forward  to  form  an  angle  with  the  shaft.  A  linear  or 
wedge-shaped  osteotomy  of  the  upper  part  of  the  tibia  has  been  described 
by  Konig  for  the  same  purpose. 

Arthrectomy. — As  a  substitute  for  excision,  what  has  been  termed 
arthrectomy  or  erasion  has  been  employed.  The  method  has  been  also 
termed  arthrotomy,  but  it  differs  essentially  from  a  simple  incision  of  the 
joint,  and  the  term  arthrectomy  is  preferable.  Erasion  is  a  misleading 
term  and  has  not  found  general  acceptance. 

Arthrectomy1  consists  of  the  removal  of  all  palpable  and  obvious  por- 
tions of  diseased  tissue,  whether  in  the  synovial  membrane  or  elsewhere, 
leaving  what  appears  to  be  healthy  tissue.  Two  advantages  are  claimed 
for  this  operation  over  excision :  (1)  That  it  does  not  interfere  with  the 
growth  of  the  limb,  and  (2)  that  mobility  of  the  joint  may  be  preserved. 
It  may  be  added  that  the  latter  is  an  exceptional  event  and  not  altogether 
so  desirable  or  safe  an  ending  under  the  circumstances  as  bony  ankylosis. 
The  objection  to  the  operation  is  that  it  is  not  thorough,  and  oftener  than 
excision  fails  to  eradicate  the  disease. 

The  operation  offers  advantage  over  excision  only  in  the  case  of  chil- 
dren, and  chiefly  before  the  disease  has  made  extensive  progress.  It  is 
easy  to  see  that,  if  any  extensive  disease  of  the  bone  is  present,  any 
measure  short  of  thorough  removal  must  necessarily  fail.  The  operation 
is,  therefore,  not  suited  to  cases  in  which  there  are  many  sinuses  and  bone 
enlargement,  but  to  milder  cases  as  a  less  severe  operation  than  formal 
excision. 

In  the  matter  of  risk  there  is  little  to  choose  between  this  operation 
and  excision,  for  the  immediate  death  rate  under  proper  precautions  is 
very  small  in  both  operations.  The  risk  of  operative  tuberculous  infec- 
tion, alluded  to  so  often  in  speaking  of  operations  upon  tuberculous  joints, 
is  present  in  arthrectomy  as  in  excisions. 

The  operation  itself  may  be  described  as  follows :  The  joint  is  opened 
as  in  cases  of  excision  and  the  tuberculous  synovial  membrane  as  far  as 
possible  should  be  dissected  out ;  if  carious  spots  are  found  in  the  bone, 
these  foci  should  be  removed  by  the  curette  or  chisel.     If  the  whole 

1  Volkmann  and  Oilier  •  Revue  de  Chirurgie,  No.  3,  1885 ;  Centralblatt  f . 
Ghirurgie,  No.  9,  1885;  Centralblatt  f.  Chirurgie,  No.  48,  1884 ;  Am.  Jour.  Med! 
Sciences,  April,  1889,  p.  369. 


334  ORTHOPEDIC   SURGERY. 

epiphysis  is  diseased,  excision  is  of  course  unavoidable.  Instances  of  ex- 
cellent recovery  with  complete  healing  occur  in  cases  of  this  sort,  and 
success  has  followed  the  procedure  in  many  cases  in  the  practice  of  the 
writers.  Strict  asepsis  is  essential,  as  well  as  most  thorough  removal 
possible  of  all  tuberculous  tissue  in  the  affected  joint,  necessitating  some- 
times complete  dissection  and  removal  of  all  of  the  synovial  membrane, 
as  well  as  careful  curetting  of  the  bone.  The  patella  should  be  removed 
or  left  according  to  its  condition. 

The  parts  of  the  knee-joint  to  be  most  carefully  investigated  for  dis- 
eased foci  are  the  synovial  pockets  and  the  epiphyseal  lines  of  the  femur 
and  tibia  at  their  lateral  aspects.  Here  one  may  find  foci  of  tuberculous 
material  extending  into  the  epiphysis,  without,  however,  in  most  cases 
crossing  the  epiphyseal  lines. 

The  after-treatment  should  be  like  that  of  excision,  except  that  wiring 
or  nailing  the  bones  together  is  not  necessary,  as  the  ligaments  should  be 
preserved  so  far  as  possible. 

Flexion  of  the  limb  may  follow  arthrectomy  as  well  as  excision  in 
cases  in  which  protection  to  the  joint  has  been  discontinued  too  early,  so 
that  the  after-treatment  should  be  as  careful  and  as  prolonged  as  after 
excision  of  the  joint. 

(3)  Amputation. — In  cases  of  extreme  disease  of  the  knee-joint  ampu- 
tation of  the  thigh  is  necessary  as  a  life-saving  measure.  As  for  the  in- 
dications determining  a  choice  between  excision  and  amputation,  it  can 
be  said  that  when  the  patient's  reparative  power  is  slight  an  amputation 
is  to  be  preferred.  The  question  is  largely  one  of  individual  judgment; 
if  excision  is  first  tried  and  fails  to  arrest  the  disease  and  finally  amputa- 
tion has  to  be  performed,  the  patient's  chances  are,  of  course,  injured  by 
the  choice  of  excision  in  the  first  place.  In  the  adult,  extensive  removal 
of  the  bones  may  be  accomplished  by  excision  without  any  danger  of 
arrest  of  growth,  and  few  patients  can  be  brought  to  consent  to  amputa- 
tion of  a  limb  so  long  as  any  other  method  of  treatment  holds  out  the 
faintest  prospect  of  relief.  In  children  amputation  should  be  deferred 
to  the  last  moment  and  excision  given  the  preference,  unless  the  eradica- 
tion of  the  disease  would  necessitate  the  removal  of  so  much  bone  that  a 
useless  leg  would  result  from  that. 

In  children,  therefore,  the  operation  could  be  advised  only  when  the 
joint  was  hopelessly  disorganized  and  so  much  of  the  shaft  of  the  long 
bones  was  evidently  diseased  that  an  excision  was  not  practicable. 

Summary. 

The  treatment  of  tumor  albus  should  consist  in  fixation  of  the  dis- 
eased joint  by  plaster  of  Paris  or  some  suitable  splint,  with  traction  in 
cases  in  which  the  muscular  spasm  is  very  marked.     If  ambulatory  treat- 


TUMOR  ALBUS  OF  THE  KNEE-JOINT.  335 

ment  is  to  be  undertaken  (which  is  almost  invariably  to  be  advised),  pro- 
tection is  also  necessary.  This  is  furnished  by  the  Thomas  splint,  a  high 
shoe,  and  crutches,  or  by  the  use  of  a  protection  splint  similar  to  the  one 
used  in  hip  disease,  etc.  Fixation  can  be  discontinued  at  the  close  of  the 
acute  stage,  but  protection  is  advisable  for  a  much  longer  time. 

Excision  is  not  an  advisable  method  of  treatment  until  mechanical 
measures  have  proved  inefficient  after  a  faithful  trial,  and  the  same  is 
true  of  arthrectomy.      Deformities  should  be  corrected  as  they  arise. 


CHAPTER  VIII. 

OTHER   DISEASES    OF   THE   KNEE-JOINT. 

Chronic  .synovitis. — Arthritis  deformans. — Cysts  of  the  knee-joint. — Bursitis. — 
Loose  bodies. — Dislocation  of  the  semilunar  cartilages. — Dislocation  of  the 
patella. — Trigger  knee.— Symptomatic  affections. — Rupture  of  the  quadriceps 
extensor  tendon. 

Chronic  •Synovitis. 

Chronic  serous  synovitis  is  most  often  the  sequel  of  the  acute  or  sub- 
acute form.  When  it  is  the  outcome  of  acute  synovitis,  the  chief  symp- 
toms of  that  affection  gradually  subside,  leaving,  however,  a  joint  partly 
full  of  fluid  and  disabled  on  that  account.  A  recurrent  subacute  or 
chronic  synovitis  also  results  from  the  irritation  caused  by  loose  bodies  in 
the  joints,  by  displacement  of  the  cartilages,  and  by  slipping  of  the 
patella.  These  should  not  be  overlooked  in  assigning  a  cause  for  any 
given  case.  When  the  affection  does  not  originate  in  an  acute  attack, 
the  earliest  symptoms  are,  usually,  impaired  motion  and  pain  with  slight 
limp,  and  occasionally  a  loss  of  strength  is  complained  of.  The  pain 
is  not  severe  unless  the  joint  is  excessively  used,  and  it  is  relieved  by 
rest.  Later,  swelling,  increased  surface  temperature,  and  redness  of  the 
skin  may  appear.  Tenderness  may  not  be  marked,  except  in  the  acute 
stages.  Generally,  when  no  constitutional  tendency  to  disease  exists  in 
simple  chronic  synovitis,  the  joint  finally  becomes  normal. 

Synovitis  of  the  knee-joint  may  remain  indefinitely  in  a  subacute  con- 
dition, with  a  slight  amount  of  effusion,  accompanied  by  thickening  of 
the  synovial  membrane,  or  a  large  amount  of  serous  effusion  may  take 
place,  with  slight  inflammatory  symptoms. 

Long-continued  chronic  synovitis  of  the  knee,  or  a  repetition  of  acute 
attacks,  may  lead  in  time  to  a  relaxed  condition  of  the  knee-joint.  Lat- 
eral mobility  becomes  evident  and  the  muscles  fail  to  control  the  joint 
with  their  former  accuracy.  It  is  this  result  which  is  to  be  feared,  as 
well  as  permanent  stiffness  in  long-continued  chronic  serous  synovitis. 

Diagnosis. — Chronic  synovitis  with  effusion  is  evidenced  by  the  en- 
largement of  the  joint  and  the  fact  that  in  the  knee  the  patella  is  lifted 
by  the  effusion,  and  floats.  In  examination  for  this  the  fingers  of  both 
hands  should  encircle  the  extended  limb  firmly  in  front,  above,  and  below 
the  patella,  thus  conhning  the  effusion  to  the  space  directly  under  the 


/ 


OTHER    DISEASES    OF    THE    KNEE-JOINT.  .','■',< 

patella  and  over  the  intercondyloid  depression  on  the  femur.  The  fore- 
finger of  one  hand  then  lightly  but  sharply  presses  on  the  patella,  which 
can  he  felt  to  descend  and  hit  the  femur.  This  matter  of  fully  extending 
the  leg  and  grasping  it  is  of  much  importance,  as  otherwise  a  small  effu- 
sion may  escape  detection. 

The  affection  most  likely  to  he  mistaken  for  chronic  serous  synovitis 
is  chronic  inflammation  of  the  prepatellar  bursa,  "housemaid's  knee." 
Here,  however,  the  swelling  is  local  and  clearly  in  front  of  the  patella, 
instead  of  being  behind  it,  and  the  patella  does  not  "  float. " 

Chronic  tumor  albus  beginning  as  an  epiphysitis  cannot  always  be 
differentiated  from  chronic  serous  synovitis. 

Hysterical  joint  disease  is  often  located  in  the  knee,  and  in  its  symp- 
toms may  simulate  chronic  synovitis  very  closely;  but  objective  signs  are 
absent.  There  is  no  effusion,  although  there  may  be  tenderness,  and  the 
whole  aspect  of  the  affection  is  more  like  ostitis  than  synovitis  in  its 
symptoms  of  local  tenderness  and  severe  spasmodic  pain. 

Treatment. — In  chronic  synovitis,  thorough  fixation  is  needed  in  the 
early  or  more  acute  stages,  with  compression. 

Compression  is  most  readily  applied  to  a  knee-joint  by  means  of  a 
thin  rubber  bandage  wound  about  the  limb ;  bandages  of  elastic  cloth  can 
also  be  used.  Dried  and  compressed  sponge,  bandaged  firmly  about  the 
limb,  will  expand  when  wet,  and  in  this  way  compress  the  tissues  of  the 
joint  effectively ;  or  the  knee  may  be  thickly  covered  with  sheet  wadding, 
outside  of  which  is  applied  binders'  board  made  pliable  by  immersion  in 
hot  water,  and  the  whole  bandaged  firmly. 

Hot  air  and  massage  are  often  of  much  value  by  improving  the  local 
circulation  and  promoting  the  absorption  of  synovial  effusions  or  its 
results.  Twists  and  sudden  jars  are  to  be  avoided,  and  protection 
(crutches  or  splints)  is  advisable  in  the  stage  of  convalescence  if  the 
attack  has  been  at  all  a  severe  or  a  protracted  one. 

Antiseptic  irrigation  or  incision  of  the  joint  have  been  advocated  for 
chronic  synovitis  of  the  knee-joint.  On  account  of  the  great  resistance 
which  many  cases  of  the  affection  offer  to  the  ordinary  methods  of  treat- 
ment, one  turns  readily  to  any  means  of  relief  which  may  be  tried  when 
the  methods  by  compression,  etc.,  have  failed.  The  fluid  in  the  joint 
may  be  withdrawn  by  aspiration  and  its  place  partly  filled  by  the  injec- 
tion of  a  few  ounces  of  either  carbolic-acid  solution  or  one  of  corrosive 
sublimate ;  the  latter  is  probably  attended  with  less  risk.  It  is  better 
that  in  such  cases  the  joint  should  be  incised  and  thoroughly  washed 
with  hot  water  or  weak  corrosive  solution. 
22 


338  ORTHOPEDIC   SURGERY. 


Arthritis  Deformans. 

The  knee  is  one  of  the  large  joints  most  frequently  attacked  by 
arthritis  deformans,  or  rheumatoid  arthritis. 

Symptoms. — Pain  and  stiffness  are  the  symptoms  at  first  complained 
of.  Pain  may  involve  the  whole  joint,  but  is  more  commonly  localized 
in  a  tender  spot  over  the  internal  conctyle  of  the  femur.  It  varies  very 
much  in  amount,  and  is  likely  to  increase  in  intensity  in  consequence  of 
exposure  to  cold  or  wet,  when  some  indiscretion  in  diet  has  been  com- 
mitted, or  as  a  result  of  over-use  of  the  affected  leg.  At  the  beginning 
of  nearly  all  cases,  pain  occurs  in  acute  attacks  accompanied  by  local 
heat,  with  tenderness  and  swelling.  The  acute  symptoms  subside,  to 
return  again  and  again,  leaving  behind  them  each  time  a  certain  amount 
of  structural  change  in  the  joint  in  the  form  of  synovial  thickening,  bony 
enlargement,  and  peri-articular  infiltration.  In  other  cases  the  affection 
progresses  slowly  and  insidiously  without  definite  acute  attacks. 

At  first  the  swelling  may  be  due  to  synovial  effusion  which  marks  the 
beginning  of  the  affection  in  many  cases ;  in  other  instances  synovial  dis- 
tention does  not  occur.  Ultimately  the  outline  of  the  joint  becomes  in- 
distinct and  a  boggy  or  hard  swelling  envelops  the  knee.  Stiffness  at 
first  passes  off  with  movement,  but  later  in  the  disease  it  becomes  per- 
manent, often  to  the  point  of  ankylosis.  Creaking  in  the  diseased  joint 
is  an  early  and  characteristic  symptom  and  reveals  only  too  plainly  the 
nature  of  the  affection. 

This  phenomenon  is  due  chiefly  to  hypertrophy  of  the  synovial  fringes, 
which  are  rubbed  together  when  the  joint  is  moved.  It  is  also  probable 
that  the  same  sensation  can  be  produced  without  any  structural  change 
by  mere  dryness  of  the  articular  surfaces.1 

In  general,  the  tendency  of  the  affection  is  toward  greater  and  greater 
impairment  of  the  joint  motion,  with  wasting  of  the  muscles  and  atrophy 
of  the  skin,  so  that  in  the  advanced  stages  one  can  see  a  stretched  and 
shining  skin  tightly  drawn  over  the  deformed  and  distorted  joint. 

The  outlook  is  unfavorable,  unless  the  disease  is  taken  in  the  early 
stages ;  not  that  life  is  likely  to  be  shortened,  but  that  serious  disability 
of  the  joint  most  often  results. 

Treatment. — During  the  acute  attacks  above  alluded  to,  when  pain 
is  caused  by  walking  and  movement,  and  heat  and  tenderness  are  present, 
rest  is  very  strongly  indicated  along  with  counter-irritation,  which  is  best 
applied  in  the  form  of  blisters  over  the  joint  or  tincture  of  iodine  painted 
on  abundantly.  Hot-water  douches,  and  compression  by  an  elastic  band- 
age or,  better  still,  by  a  Gamgee  dressing  of  millboard  and  sheet  wadding, 
are  also  of  much  benefit. 

•Cent.  f.  Chir.,  October  15th,  1887. 


OTHER   DISEASES    OF   THE   KNEE-JOINT.  339 

A  few  days  will  generally  suffice  to  quiet  the  acute  symptoms.  Dur- 
ing the  quiescent  stage,  the  best  local  measures  are  massage,  counter- 
irritation,  hot  douching,  the  hot-air  bath,  and  protection  of  the  joint  by 
a  warm  covering,  such  as  a  flannel  bandage;  moderate  exercise  is  also  to 
be  regarded  as  a  therapeutic  measure,  when  it  is  not  attended  by  discom- 
fort. If  pain  is  excessive,  one  has  to  face  the  dilemma  of  continuing 
motion  which  is  excessively  painful  or  of  allowing  the  patient  to  rest  and 
keep  the  joint  still,  by  which  process  one  is  likely  to  favor  the  stiffening 
of  the  joint,  if  it  is  continued  for  too  long  a  time.  For  short  periods, 
however,  there  is  no  risk,  and  sometimes  much  to  be  gained  by  complete 
rest  to  the  affected  articulation. 

Much  importance  in  the  matter  of  treatment  is  to  be  attached  to  gen- 
eral measures,  and  when  it  is  practicable,  a  visit  to  some  well-chosen 
health  resort  is  likely  to  be  of  benefit.  The  benefit  of  the  waters  and 
baths  in  these  places,  along  with  the  change  of  scene  and  a  carefully 
regulated  diet  and  regime,  often  accomplish  much. 

Such  a  measure  of  treatment,  however,  is  out  of  the  reach  of  the 
majority  of  patients,  and  one  has  to  consider  much  more  often  the  method 
which  is  likely  to  be  of  most  use  at  home. 

The  diet  should  be  carefully  regulated. 

Water,  which  will  act  as  a  diuretic,  should  be  taken  in  measured 
quantity  daily  (from  one  to  two  quarts  at  least).  Lithia  waters  are 
useful,  but  in  many  of  the  natural  waters  the  quantity  of  the  drug  con- 
tained is  so  small  that  it  is  better  to  resort  to  an  artificial  water  contain- 
ing a  definite  amount  of  the  drug.  A  very  useful  addition  to  the  water 
taken  at  meals  is  a  teaspoonful  of  the  imported  Vichy  salt,  or  of  one  of 
the  artificially  prepared  effervescent  Vichy  salts  sold  here. 

It  is  desirable  to  take  a  hot  bath  at  least  twice  each  week,  to  promote 
secretion  by  the  skin,  and  the  bowels  should  be  kept  active  by  saline 
laxatives.  Hydrotherapy  properly  practised  is  of  value.1  General  and. 
local  massage  is  a  resource  of  the  greatest  value,  and  a  mild  galvanic 
current  is  also  of  much  benefit  as  a  promoter  of  proper  circulation. 

Less  is  to  be  expected  in  the  matter  of  drugs  than  from  general 
hygiene  and  treatment.  Salicin  or  salicylate  of  soda  in  ten-grain  doses, 
three  times  daily,  often  has  a  marked  effect  in  controlling  the  affection, 
and  an  alkaline  diuretic  is  almost  a  necessity.  Lithia,  or  the  salicylate 
of  lithia,  at  other  times  accomplishes  more  than  salicylic  acid  does. 
Arsenic  is  sometimes  useful  to  a  marked  degree,  but  iodide  of  potassium  is 
not  generally  of  much  benefit.  Tonics  should  be  given  in  the  form  of 
iron  or  quinine,  or  strychnine,  if  the  general  condition  is  not  good  or  if 
the  appetite  flags. 

When  ankylosis  of  the  knee  in  a  faulty  position  has  resulted  from 

1  Baruch  :  "  Hydrotherapy,"  New  York,  1898. 


340  ORTHOPEDIC    SURGERY. 

rheumatoid  arthritis,  briseuient  force  is  to  be  tried  for  its  rectification,  as 
described  for  the  correction  of  ankylosis  after  tumor  albus.  It  is  not,  of 
course,  to  be  expected  that  motion  will  be  present  in  the  joint  in  its  new- 
position,  for  the  structural  changes  must  have  already  been  extensive  to 
have  induced  the  deforming  ankylosis,  yet  some  motion  may  be  preserved 
in  the  joint.  Excision  of  the  knee  may  be  required  in  cases  which  are 
so  firmly  ankylosed  as  to  resist  the  surgeon's  attempt  at  straightening. 

When,  however,  the  ankylosis  is  the  outcome  of  a  simple  rheumatic 
synovitis  occurring  in  the  course  of  an  acute  or  chronic  attack  of  rheu- 
matism, forcible  manipulation  may  break  up  the  adhesions  which  have 
caused  the  joint  stiffness  and  restore  a  certain  amount  of  permanent 
motion  to  the  articulation.  These  cases  are  to  be  distinguished  from  the 
ankylosis  of  arthritis  deformans  by  the  fact  that  in  the  former  the  joint 
is  practically  normal  in  outline  and  there  is  no  bony  enlargement  of  that 
or  the  other  joints  described  as  a  characteristic  of  arthritis  deformans. 

Cysts    of    the    Knee-Joint. 

The  occurrence  of  cystic  swellings  in  connection  with  the  larger 
joints,  especially  the  knee-joint,  was  called  attention  to  by  Baker.1 
These  swellings  are  found,  from  time  to  time,  in  the  neighborhood  of  the 
knee-joint,  generally  in  the  popliteal  space.  At  first  there  is  nothing  to 
suggest  their  connection  with  the  joint  in  any  way,  for  the  cyst  may  be 
at  a  considerable  distance  from  the  joint.  There  may  be  no  fluctuation 
to  be  obtained  between  the  joint  and  the  cyst,  nor  can  the  fluid  from  the 
cyst  be  pressed  into  the  joint;  in  fact,  there  may  be  no  evidence  of  effu- 
sion in  the  joint. 

In  this  case  it  is  difficult  to  believe  that  any  connection  exists  between 
the  cyst  and  the  articulation,  but  Baker  pointed  out  the  almost  universal 
connection  of  these  cysts  with  the  joint  cavity. 

As  a  rule,  there  is,  or  has  been,  a  certain  amount  of  effusion  into  the 
joint  which  has  escaped  into  the  neighboring  bursas  or  into  a  hernial  pro- 
trusion of  the  synovial  membrane,  while  in  other  cases  it  seems  clear  that 
the  affection  of  the  joint  was  secondary  to  a  bursitis. 

Biese2  has  advanced  the  view,  however,  that  these  swellings  are  true 
cystic  tumors  of  degenerated  fibrous  tissue  and  not  outgrowths  or  hernias 
of  the  capsule.  He  bases  this  view  on  the  existence  of  an  obliterating 
endarteritis  of  the  vessels  supplying  them.  The  affection  is  found  most 
often  in  early  and  middle  adult  life. 

The  diagnosis  from  bursitis  is  often  difficult. 

Extirpation  of  the  sac  is  the  only  treatment  likely  to  be  of  use. 

'"St.  Bartholomew's  Hospital  Reports."  vol.  xiii.,  p.  245;  vol.  xxi.,  p.  177. 
» Cent.  f.  Chir.,  1898,  p.  585. 


OTHKIi   DISKAMES    <)K    THE    KNEE-JOINT. 


?Al 


Bursitis    ov    the    Knee. 

The  various  bursse  about  the  knee  may  become  inflamed  and  give  rise 
to  disability  of  an  obscure  nature. 

Housemaid's  Knee. — -The  most  common  seat  of  this  affection  is  in 
the  prepatellar  bursa  which  lies  over  the  patella  and  part  of  the  ligamen- 
tum  patellae.  This  is  not, 
as  a  rule,  one  well-defined 
sac,  but  consists  of  three 
layers  of  bursae  more  or  less 
well  marked  and  generally 
in  communication  with  each 
other  and  at  times  with  the 
knee-joint.  The  three  layers 
are  classed  by  Bize1  as 
subcutaneous,  subaponeurot- 
ic, and  subtendinous. 

This  affection  is  found 
chiefly  in  persons  whose  oc- 
cupation leads  them  to  spend 
much  time  in  kneeling. 
The  acute  affection  is 
brought  about  by  over-use 
of  the  knee  and  is  character- 
ized by  slight  swelling,  sen- 
sitiveness on  pressure,  and 
discomfort  in  flexing  the 
knee,  which  is  localized  at 
the  site  of  the  bursa.  Pal- 
pation shows  a  more  or  less 
distinct  swelling,  which  lies 
over  the  patella  and  which 
is  rendered  more  tense  by 
the  flexion  of  the  joint.      In 

the  acute  stage  it  is  likely  to  be  mistaken  for  synovitis  of  the  knee-joint, 
especially  as  the  inflammation,  if  neglected,  tends  to  spread  and  the  swell- 
ing may  become  more  diffuse  and  burrow  around  the  joint;  although  the 
chronic  enlargement  of  the  bursa  is  sometimes  primary,  more  often  it  is 
the  outcome  of  a  series  of  acute  attacks.  Fluctuation  is  clearly  present, 
and  the  swelling  is  more  sharply  localized  to  the  region  in  front  of  the 
patella  than  in  synovitis.  In  the  chronic  stage  of  the  affection,  heat,  sen- 
sitiveness, and  discomfort  are  ordinarily  absent,  except  a  slight  feeling  of 
stiffness  in  complete  flexion  of  the  leg. 


Fig.  308.— Prepatellar  Bursitis. 


1  Journ.  d'Anat.  et  de  Phys.,  Paris,  xxxii.,  1896,  p.  85. 


342  ORTHOPEDIC    SURGERY. 

For  diagnosis,  one  must  depend  upon  the  facts  that  the  swelling  is 
entirely  in  front  of  the  patella,  that  the  patella  does  not  float,  that  the 
joint  is  not  affected,  and  that  the  occupation  of  the  patient  in  some  way 
has  produced  continual  slight  injuries  of  this  region.  Although  the  acute 
affection  shows  a  tendency  toward  recovery  under  rest,  the  chronic  affec- 
tion does  not  have  this  tendency  and  is  likely  to  continue  unabated. 

Suppuration  occurs  in  both  acute  and  chronic  varieties  in  a  certain 
proportion  of  cases;  and  it  is  generally  in  consequence  of  some  depleted 
condition  of  the  system  or  some  local  aggravation.  The  inflammation  of 
the  bursa  occasionally  occurs  in  connection  with  gout,  rheumatism,  or 
syphilis. 

Treatment. — The  acute  affection,  unless  too  far  advanced,  ordinarily 
yields  readily  when  the  limb  is  placed  in  the  extended  position  upon  a 
ham  splint,  and  the  constant  irritation  of  walking  is  avoided.  Painting 
the  skin  with  iodine  and  the  application  of  pressure  either  by  sheet  wad- 
ding and  bandages,  or  by  an  elastic  flannel  bandage,  is  of  much  assistance 
in  allaying  the  inflammation ;  a  few  days  or  weeks  in  the  milder  cases 
will  ordinarily  reduce  the  inflammation.  In  old  cases  this  treatment  has 
little  or  no  effect.  If,  however,  the  bursitis  has  reached  the  stage  of 
suppuration,  incision  affords  the  only  hope  of  relief. 

In  chronic  bursitis,  either  the  bursa  may  be  aspirated  and  pressure 
afterward  applied,  or  the  knee  may  be  let  alone.  The  discomfort  is  so 
slight  that  occasionally  patients  very  much  prefer  to  have  nothing  done. 
The  most  satisfactory  treatment  in  chronic  cases  is  to  lay  the  entire  bursa 
open  by  a  crucial  incision,  and  either  dissect  out  the  tough  fibrous  sac 
which  will  be  found  there,  or  having  laid  it  open,  scrape  it  out  very 
thoroughly  with  a  curette.  Any  other  measure  is  useless,  when  the  in- 
flammation has  reached  the  stage  of  suppuration. 

Bursitis  of  the  Deep  Prepatellar  Bursa. — The  affection  of  this 
bursa  presents  certain  characteristic  symptoms  often  difficult  to  differ- 
entiate from  those  of  synovitis.  This  bursa  lies  beneath  the  ligamentum 
patellae  next  to  the  tibia.  It  rises  as  high  as  the  upper  edge  of  the  tibia 
and  is  triangular  in  shape,  the  apex  of  the  triangle  being  downward  near 
the  tubercle  of  the  tibia.  This  bursa  practically  never  communicates  with 
the  knee-joint.1 

The  inflammation  of  this  bursa  is  described  under  various  names,  one 
of  them  being  Pseudarthrose  du  Genou.'2 

The  peculiar  symptoms  of  this  affection  are  pain  in  complete  extension 
of  the  leg,  referred  to  the  tubercle  of  the  tibia ;  pain  and  tenderness  re- 
ferred to  the  patella  tendon ;   apparent  enlargement  of  the  tubercle  of  the 


'Lovett:  Boston  City  Hosp.  Reports,  8th  series,  p.  345. 

'•'  Dubreuil :  Annales  d'Orth.,  Paris,  September,  1890;  Archiv  f.  klin.  Chir., 
1877, xxi.,  132  ;  "Traite"  de  Path,  ext."  (Follin).  iii.,  19  ;  Pitha  and  Billroth  :  "Chirur- 
gie."  iv.,  1,  Heft  2,  p.  242  ;  Feraud  :    These  de  Montpelier,  1880. 


OTHER    DISEASES   OF   THE    KNEE-JOINT.  343 

tibia,  and  bulging  at  the  sides  of  the  ligamentum  patellae.  The  affection 
may  be  mistaken  for  inflammation  of  the  superficial  pretibial  bursa1  or 
for  the  inflammation  of  abnormal  bursee  in  this  neighborhood.2  Careful 
examination  will  usually  differentiate  it  from  synovitis  of  the  knee-joint. 

The  treatment  does  not  differ  from  that  of  housemaid's  knee  except 
that  bursitis  of  the  deep  pretibial  bursa  is  more  obstinate. 

The  inflammation  of  other  bursae  about  the  knee-joint  presents  no 
peculiar  symptoms,  and  the  existence  of  the  affection  is  made  evident  by 
the  presence  of  a  fluctuating  swelling  at  the  site  of  a  bursa. 

Loose  Bodies  in  the  Knee- Joint. 

The  pathology  and  formation  of  loose  bodies  has  already  been  consid- 
ered. It  has  been  stated  that  nine-tenths  of  all  the  cases  occur  in  the 
•knee-joint.  In  a  majority  of  cases  the  first  intimation  to  the  patient  that 
anything  is  wrong  is  that  while  in  the  act  of  walking  or  stooping  he  is 
seized  with  such  agonizing  pain  in  the  knee  that  he  may  fall  to  the 
ground,  in  many  cases  overcome  with  the  sensation  of  faintness  and  sick- 
ening pain.  At  times  this  pain  subsides  almost  immediately,  and  the 
patient  is  able  to  walk  within  a  few  minutes;  but  at  other  times  the 
joint  remains  fixed  in  a  position  of  more  or  less  flexion,  and  any  attempt 
to  move  it  is  attended  with  very  severe  suffering.  In  any  event,  such 
an  occurrence  is  apt  to  be  followed  by  an  attack  of  synovitis  lasting  sev- 
eral days.  Up  to  this  time  the  joint  may  have  been  normal  and  given  no 
trouble,  or  it  may  have  been  the  seat  of  chronic  inflammation.  These 
attacks  are  likely  to  be  repeated  without  any  assignable  cause.  On 
manipulation  of  the  joint  with  the  fingers,  it  is  often  possible  to  detect  a 
loose  body  which  shifts  its  position  and  is  found  first  in  one  part  of  the 
joint  and  then  in  another.  The  most  common  spot  where  they  can  be 
detected  externally  is  in  the  pouch  over  the  external  or  internal  condyle 
of  the  femur.  They  are  felt  as  smooth  slippery  bodies  under  the  skin, 
which  evade  the  fingers'  grasp  with  surprising  readiness.  Occasionally 
they  may  be  found  over  the  tibia  inside  the  ligamentum  patellae,  and 
when  one  of  these  substances  has  been  found  it  is  desirable  to  see  if 
others  are  present  in  the  joint.  Sometimes  it  is  impossible  to  detect  any 
loose  bodies  from  the  outside,  and  the  history  of  the  case  must  be  de- 
pended upon  to  establish  the  diagnosis.  In  some  cases  the  attacks  are  of 
very  frequent  occurrence,  while  in  others  it  is  only  at  intervals  of  several 
weeks  or  months  that  the  joint  gives  any  trouble. 

With  repetition  of  attacks  the  joint  becomes  more  tolerant  and  the 
synovitis  less  severe.  In  cases  in  which  arthritis  deformans  is  present  as 
the  cause  of  the  loose  bodies,  the  history  of  the  attacks  is  less  typical. 

1  Monks  and  Richardson  :  Boston  Med.  and  Surg.  Join-.,  December  18th,  1890. 
2Delore:  Gaz.  Heb.  de  Med.  et  de  Chir.,  June  2d,  1894. 


344 


ORTHOPEDIC    SURGERY. 


The  patient,  however,  experiences  in  a  measure  the  same  sudden  catching 
of  the  joint,  and  movement  of  the  affected  knee  is  painful,  restricted, 
and  attended  with  a  particularly  distinct  grating. 

Finding  a  movable  body  which  can  be  slipped  from  place  to  place  by 
manipulation  establishes  the  diagnosis. 

In  cases  in  which  the  loose  body  cannot  be  found,  one  must  depend 
largely  upon  the  history  ;  making,  however,  frequent  examinations  under 

different  conditions  with  the 
hope  of  ultimately  detecting  the 
foreign  body. 

The  diagnosis  between  inter- 
nal derangement  of  the  knee- 
joint  and  a  loose  cartilage  is 
often  a  difficult  one  to  make,  and 
dependence  must  be  placed 
chiefly  upon  tenderness  in  a  very 
small  spot  over  the  head  of  the 
tibia  as  establishing  the  probable 
occurrence  of  dislocation  of  one 
of  the  semilunar  cartilages.  In 
the  majority  of  cases  of  loose 
bodies,  on  the  other  hand,  it  is 
possible  ultimately  to  detect  ex- 
ternally their  presence,  as  caus- 
ing the  trouble. 

In  cases  in  which  the  loose 
body  gives  but  little  inconveni- 
ence and  is  kept  from  passing 
between  the  ends  of  the  bone  by 
a  knee-cap  it  may  not  be  advis- 
able to  undertake,  operative  treat- 
ment.    In  other  cases,  especially 
in  arthritis  deformans,  the  joint 
may  have  become  so  much  im- 
paired by  the  disease  that  even 
if  a  foreign  body  were  removed 
little  would  be  gained.     In  the   great  majority  of  cases,  however,  inas- 
much as  the  disease  occurs  in  otherwise  healthy  persons,  mostly  young 
adults,  any  operation  which  does  not  entail  serious  risk  is  advisable. 

Woodward  was  able  to  collect  105  cases  in  which  a  direct  antiseptic 
incision  of  a  joint  had  been  made  for  the  removal  of  a  foreign  body.  In 
104  of  these  the  knee  was  the  joint  affected,  and  92  of  these  were  for  the 
removal  of  loose  cartilages.  In  1  case  the  foreign  body  proved  to  be  a 
sarcoma,  in  1  a  fibroma,  and  in  1  a  lipoma.      In  2  cases  nothing  could 


Fig.  309.— Charcot's  Disease  of  Knee.    (Weigel.) 


OTHER   DISEASES    OE   THE    KNEE-JOINT.  345 

be  found,  and  in  1  of  these  adhesions  behind  the  back  of  the  patella 
were  forcibly  broken  up.  There  was  but  J  death  in  these  105  operations, 
and  that  was  due  to  phlegmonous  erysipelas,  so  that  the  asepsis  of  this 
operation  is,  at  least,  doubtful.  The  same  may  be  said  of  2  other  cases 
in  which  suppuration  necessitated  amputation  of  the  thigh,  while  stiffness 
of  the  affected  joint  resulted  in  3  cases;  in  1  of  which  400  loose  cartilages 
had  been  removed,  in  another  24,  and  in  a  third  4.  In  4  other  cases  be- 
sides these,  slight  impairment  of  motion  was  reported. 

In  complicated  cases,  of  course,  there  is  a  possibility  of  more  or  less 
resulting  stiffness.  The  list  of  105  cases  is  given  in  full  in  Woodward's 
paper. '     The  operation  is  performed  as  follows : 

The  loose  body  having  been  found,  a  needle  is  passed  through  it  from 
the  outside  to  steady  it,  and  it  is  then  cut  down  upon  by  careful  dissec- 
tion until  it  is  exposed  and.  removed.  After  the  removal  of  the  body 
originally  detected,  the  joint  should  be  carefully  examined  to  see  if  others 
are  present.  In  a  case  in  which  continual  trouble  was  caused,  an  explora- 
tory incision  into  the  knee-joint  would  be  attended  with  very  slight  risk 
and  might  be  of  great  benefit  in  discovering  the  presence  of  peduncu- 
lated loose  bodies  which  escaped  detection  from  the  outside.  There  is, 
of  course,  a  slight  tendency  to  the  re-formation  of  these  bodies  after  one 
or  more  have  been  removed. 

With  regard  to  the  treatment  of  the  synovitis  which  is  caused  by  the 
"  catching  "  of  the  limb,  a  few  days'  rest  will  be  sufficient  to  quiet  it. 
The  patient  soon  acquires  the  habit  of  straightening  the  limb  himself, 
after  the  attack,  when  it  is  fixed  in  a  flexed  position. 

Dislocation  of  the  Semilunar  Cartilagks. 

(Hey's  Internal  Derangement.) 

The  term  "  internal  derangement "  had  its  origin  in  the  term  given  by 
Hey  in  1803 "  describing  the  condition.  The  condition  was,  however, 
previously  described  by  William  Bromfield  in  1753. 

The  affection  is  nearly  always  traumatic  in  origin  and  consists  in  the 
tearing  loose  from  its  tibial  attachment  of  the  internal  or  external  semi- 
lunar cartilage.  The  internal  is  the  one  most  frequently  displaced.  This 
is  probably  for  two  reasons:  first,  because  it  has  less  mobility  on  the 
tibia  than  the  external,  and  secondly,  the  motion  most  likely  to  displace 
it.  forcibly  is  outward  rotation  of  the  tibia  on  the  femur,  or  what  has  the 
same  effect,  inward  rotation  of  the  femur  on  the  tibia.  It  must  be  re- 
membered that  the  knee  is  not  a  strictly  hinge  joint,  but  that  in  exten- 

'  Boston  Med.  and  Surg.  Jour.,  April  25th,  1889. 

2  Hey :  "Practical  Observations  in  Surgery,"  1808  ;  W.  Bromfield  :  " Chirorgical 
Observations,"  4  cases,  vol.  ii.,  1753. 


346  ORTHOPEDIC   SURGERY. 

sion  the  leg  rotates  outward  upon  the  thigh,  especially  at  the  end  of 
extension  when  a  quick  outward  rotation  of  the  tibia  occurs,  locking  the 
leg  in  complete  extension. 

A  sudden  wrench  or  twist  in  slight  flexion  is  the  accident  most  often 
causing  displacement  of  these  cartilages. 

The  symptoms  are  in  a  measure  similar  to  those  described  under  loose 
cartilage.  The  patient  by  some  violent  muscular  effort  or  by  some  sud- 
den twist  as  in  kicking  football  or  falling  from  a  horse  or  carriage, 
wrenches  the  knee  and  finds  it  impossible  to  fully  extend  it,  and  walks 
with  it  bent  in  the  way  described,  suffering  much  pain. 

In  some  instances  much  tenderness  can  be  found  over  the  inner  tuber- 
osity of  the  tibia  where  none  was  present  over  the  outer  tuberosity ;  and 
Marsh  photographed  a  case  which  shows  externally  a  depression  over  the 
situation  of  the  internal  semilunar  cartilage.  This  sudden  locking  of  the 
joint,  so  far  as  extension  is  concerned,  is  almost  the  only  characteristic 
symptom  of  internal  derangement;  but  generally  on  examination  one 
finds  a  protrusion  of  one  of  the  semilunar  cartilages.  This  establishes 
the  diagnosis,  and  a  sharp  attack  of  synovitis  of  course  follows  such  a 
severe  injury  to  the  joint. 

The  most  marked  cases  happen  after  some  serious  wrench  to  the  joint. 
Nevertheless,  cases  occur  in  which  the  cartilage  is  perhaps  only  relaxed, 
and  in  these  a  much  less  painful  locking  of  the  joint  arises.  The  affec- 
tion is  masked  in  many  patients  by  the  severity  of  the  acute  synovitis 
which  follows  the  injury,  and  the  true  character  of  the  accident  may  not 
be  learned  for  a  long  time  afterward  unless  its  history  is  most  carefully 
inquired  into.  One  occurrence  of  the  accident  predisposes  to  subsequent 
attacks.  Lateral  mobility  of  the  knee  is  likely  to  exist  in  cases  of  long 
standing. 

Internal  derangement  of  the  knee-joint  affects,  for  the  most  part, 
persons  between  twenty  and  fifty  years  of  age ;  men  are  much  more  fre- 
quently affected  than  women  ;  it  occasionally  occurs  in  children. 

Patients  who  are  liable  to  the  displacement  soon  learn  the  manipula- 
tion of  reduction  themselves.  The  knee  should  be  bent  to  its  fullest  ex- 
tent, the  tibia  should  then  be  drawn  away  from  the  femur  as  far  as  pos- 
sible, to  separate  the  joint  surfaces,  at  the  same  time  rotating  the  tibia 
inward  or  outward  as  the  internal  or  external  cartilage  is  displaced,  and 
then  the  leg  should  be  extended  quickly  but  not  forcibly  to  its  fullest 
extent,  while  the  surgeon  manipulates  with  the  thumb  the  situation  of 
the  semilunar  cartilages,  especially  if  any  undue  prominence  should  be 
felt.  An  anaesthetic  is  very  often  necessary  or  advisable.  The  reduc- 
tion in  exceptional  instances  cannot  be  effected,  but  commonly,  and  espe- 
cially with  the  use  of  an  anaesthetic,  reduction  takes  place  easily  and  a 
distinct  click  is  heard  in  many  cases. 

The  cartilage  may  after  reduction  become  united  to  the  tibia  by  its 


OTHER    DISEASES    OV    THK    KNEK-.IOINT. 


:'>47 


former  attachments  or  it  may  remain  loose  to  cause  further  attacks.      It 
may  he  simply  torn  from  its  tihial  attachments  and  remain  attached  as 

before  at  its  two  ends,  or  it  may  also  be  torn 
across  in  the  middle,  and  the  free  end  may 
cause  trouble  by  acting  practically  as  a  loose 
body.  Finally,  entire  detachment  of  the  torn 
piece  may  occur,  in  which  case  it  becomes  a 
loose  body  of  the  cartilaginous  class. 

The  treatment  after  the  original  accident  is 
reduction  of  the  displaced  cartilage,  followed 
by  the  usual  treatment  for  the  acute  synovitis 
which  ensues. 

If  the  attacks  recur,  especially  on  slight 
cause,  it  is  likely  that  the  cartilage  has  been 
permanently  loosened  from  its  attachments  and 
will  be  in  all  probability  a  source  of  further 
trouble.  The  treatment  may  under  these  cir- 
cumstances be  mechanical  or  operative. 

(1)  Mechanical  Treatment.- — Although  the 
use  of  knee-caps  with 
pads  beside  the  patella, 
elastic  bandages,  etc., 
may  prove  of  use  in  pre- 
venting in  part  future 
attacks,  they  can  hardly 
be  recommended  as  a 
form  of  treatment  on  ac- 
count of  the  great  incon- 
venience attending  their 
use,  and  the  fact  that 
they  are  to  be  regarded  as 
palliative  rather  than 
curative. 

The  mechanical  treat- 
ment advocated  by  Shaffer 
for  this  condition  will  be 
described  in  the  follow- 
ing section  (page  351). 
(2)  Operative  treat- 
ment is,  as  a  rule,  surer,  quicker,  and  more  acceptable  to  the  patient. 
The  joint  is  opened  inside  or  outside  of  the  ligamentum  patella?  accord- 
ing to  the  cartilage  displaced,  by  a  transverse  or  vertical  incision.  If 
the  cartilage  has  simply  been  detached  from  its  coronary  attachment  and 
not  torn  across,  the  detached  portion  should  be  stitched  to  the  capsule 


Fig.  310.— Tumor  of  Femur  Involving  Knee. 


348 


ORTHOPEDIC    SURGERY 


and  other  fibrous  structures  covering  the  head  of  the  tibia.  If  the  carti- 
lage has  been  detached  and  also  torn  across,  the  loose  portion  should  be  re- 
moved. Whichever  operation  is  performed,  the  joint  should  of  course  be 
explored  and  the  wound  closed.  Fixation  should  follow  for  about  six 
weeks,  followed  by  massage  and  passive  motions. 

Dislocation  ok  the  Patella. 

Dislocation  of  the  patella  or  slipping  patella  is  likely  to  occur  either 
spontaneously  or  for  very  slight  cause  in  certain  young  girls   with   lax 


Fig.  311.— Patella  in  Normal  Position. 


muscular  fibre  and  a  feeble  development,  and  boys  are  only  exceptionally 
attacked. 

In  consequence  of  some  slight  twist  of  the  leg,  as  in  dancing,  rising 
from  a  chair,  going  upstairs,  or  some  similar  motion,  an  excruciating 
pain  is  felt  in  the  knee,  and  the  person  either  falls  in  consequence  of 
faintness,  or  finds  herself  unable  to  use  the  leg.  Very  often  the  patient 
herself  hears  a  cracking  sound  when  the  dislocation  occurs.     The  patella 


OTHKR   DISEASES    OP    'INK    KNEE-JOINT. 


349 


is  found  almost  always  dislocated  outwardly,  sometimes  twisted  so  that 
its  lateral  edge  rests  against  the  front  of  the  femur  (vertical  luxation  of 
Malgaigne).  The  reduction  of  the  dislocation  is  very  simple,  and  is  very 
soon  learned  by  the  patients  themselves.  The  leg  is  fully  extended  and 
the  patella  gently  pressed  back  into  place  until  it  assumes  its  proper 


FKi.  :jia. — Patella  Dislocated. 

place  with  a  click,  or  often  it  slips  back  of  its  own  accord  when  the  leg 
is  straightened.  An  attack  of  synovitis  follows,  as  in  the  case  of  loose 
bodies,  but  the  joint  soon  acquires  a  tolerance  so  that  each  succeeding 
attack  of  synovitis  becomes  less. 

The  cause  of  the  affection  seems  to  be,  in  most  cases,  the  lack  of 
tonicity  in  the  extensor  muscles  of  the  thigh,  or  the  elongation  of  the 
ligamentum  patella?,  but  very  commonly  the  former. 

After  many  attacks  of  dislocation  the  patients  complain  of  a  certain 
sense  of  insecurity  in  walking  which  in  severe  cases  may  amount  to  a 
distressing  disability,  limiting  the  patient's  ability  to  walk  or  engage  in 
active  occupation. 

Congenital  dislocation  of  the  patella  is  considered  under  Congenital 
Dislocations. 


350 


ORTHOPEDIC    SURGERY 


Mechanical  Means  for  Securing  a  Slipping  Patella. — There  are  many 
devices  for  retention  of  a  slipping  patella.  The  elastic  knee-cap,  which 
is  frequently  recommended,  will  be  found  of  little  service;  it  presses 
the  patella  downward  upon  the  femur  without  exerting  pressure  on 
the  sides  of  the  patella.  If,  however,  an  elastic 
knee-cap  is  split  in  front  and  furnished  with  lac- 
ings or  straps,  and  if  felt  pads  are  sewn  upon  the 
sides  of  the  cap  at  such  places  as  would  exert 
pressure  upon  the  sides  of  the  patella,  an  ar- 
rangement is  furnished  which,  when  properly  ad- 
justed, will  give  a  serviceable  support  in  lighter 
cases,  allowing  motion  at  the  knee.  A  more  effi- 
cient and  less  comfortable  support  can  be  made  by 
taking  a  cast  of  the  limb,  and  upon  this  moulding 
a  leather  knee-cap,  which  can  be  laced  about  the 
lower  thigh,  knee,  and  leg.  This  does  not  per- 
mit bending  at  the  knee,  but  exercises  some  pres- 
sure on  the  sides  of  the  patella  and  entirely 
prevents  its  slipping.  It,  however,  favors  the 
development  of  atrophy,  but  is  of  value  after  a 
severe  attack  followed  by  effusion,  and  is  a  means 
of  retention  of  the  patella  until  the  strained  liga- 
ments have  recovered  their  strength. 

The  following  steel  appliance  will  be  found  of 
service :  It  consists  of  two  uprights,  hinged  at  the 
knee,  extending  from  the  middle  of  the  calf  to  the 
middle  of  the  thigh  on  each  side  of  the  limb,  and 
connected  with  cross-pieces  above  and  below.  To 
these  are  attached  at  the  level  of  the  middle  of 
the  patella  semilunar  plates,  which  are  of  such  a 
shape  and  are  bent  in  such  a  way  as  to  press  upon 
the  sides  of  the  patella.  They  are  covered  with 
padding  and  leather.  If  leather  straps  pass  diag- 
onally from  the  uprights  to  buttons  upon  the  top 
and  bottom  of  these  plates,  an  adequate  amount  of  side  pressure  will  be 
secured.  Two  straps  from  underneath  the  knee  prevent  the  apparatus 
from  falling  forward,  and  the  straps  mentioned  prevent  the  apparatus 
from  slipping  backward.  It  is  essential  that  this  appliance  should  not 
remain  in  a  bent  position,  as  the  pressure  at  the  sides  of  the  patella 
would  in  that  case  be  diminished.  To  prevent  this  a  spring  is  furnished 
connecting  the  upper  portion  of  the  upright  with  the  lower  portion,  with 
sufficient  strength  to  force  the  appliance  into  a  straight  position,  but 
allowing  bending  of  the  knee  by  muscular  effort. 

Massage  and  Electricity.  — It  is  manifest  that  no  cure  can  take  place 


Fig.  313.— Strap  to  Re- 
strain Slipping  Patella.  A, 
Strip  of  leather  to  which  a 
rubber  tube  is  secured,  press- 
ing against  outer  edge  of 
patella ;  B,  a  piece  of  ad- 
hesive plaster  secured  to  the 
leather  and  applied  to  the 
outer  side  of  knee;  C  C, 
webbing  strap  fastened  to 
waist  and  boot  and  by 
buckles  to  leather  piece  A. 


OTHER   DISEASES    OE    THE    KNEE-JOINT.  351 

except  through  the  development  of  the  muscles  or  improvement  in  the 
strength  or  length  of  the  ligaments.  In  certain  cases  reliance  can  be 
placed,  upon  the  natural  development  in  the  growth  of  the  patient,  and  it 
is  simply  necessary  for  recovery  to  protect,  during  the  growing  period, 
the  ligaments  from  the  additional  strain  of  the  frequently  displaced  pa- 
tella.    Massage  and  electricity  are  manifestly  indicated  in  all  cases. 

Operative  treatment  consists  in  the  removal  of  an  elliptical  piece  of 
the  front  of  the  capsule  of  the  joint  internal  to  the  extensor  tendon  and  a 
stitching  together  of  the  edges  of  the  opening,  thereby  tightening  the 
inner  part  of  the  capsule.  This  operation  has  been  performed  by  Bijardi, ' 
Gavin"  (quoted  by  Bradford),  Perkins,  of  Kansas  City  (traumatic),  Brad- 
ford,0 Lovett, '  and  others.  Goldthwait  has  transplanted  the  ligamen- 
tum  patelhe  inward  in  a  case  with  knock-knee,  and  in  a  later  case  the 
tubercle  of  the  tibia  was  transplanted  inward  with  its  attachments. " 

In  resistant  cases  a  vertical  incision  outside  of  the  patellar  tendon 
must  also  be  made  to  allow  the  patella  to  be  pulled  into  place  by  the 
tightening  of  the  capsule  on  the  inner  side. 

Mechanical  Treatment  of  Elongation  of  the  Lig amentum  Patella}  and 
Dislocation  of  the  Semilunar  Cartilage. — A  form  of  mechanical  treatment 
for  the  correction  of  elongation  of  the  patellar  tendon  has  been  advocated 
by  Shaffer,  which  is  applicable  to  cases  of  recurrent  dislocation  of  the 
semilunar  cartilages.  This  has  for  its  basis  the  supposition  that  an  elon- 
gation of  the  ligamentuni  patellae  is  a  causative  factor  in  at  least  some  of 
the  cases  of  dislocation  of  the  cartilages.0  This  factor  was  noticed  by 
Hey  as  follows :  "  If  there  is  any  difference  from  its  usual  appearances, 
it  is  that  the  ligament  of  the  patella  appears  rather  more  relaxed  than 
in  the  sound  limb.  .  .  .  The  patient  himself  cannot  freely  bend  nor 
perfectly  extend  the  limb  in  walking,  but  is  compelled  to  walk  with  an 
invariable  and  small  degree  of  flexion." 

Shaffer  in  ten  cases  of  slipping  cartilage  described  an  abnormally  high 
position  of  the  patella  on  the  affected  side,  being  from  one-quarter  of  an 
inch  to  an  inch  higher  than  on  the  sound  side.  The  treatment  advocated 
and  found  efficient  by  Shaffer  is  the  application  of  an  apparatus  to  the 
thigh,  leg,  and  foot,  allowing  only  the  hinge  motion,  thus  preventing,  at 
least  in  large  measure,  the  slight  rotation  at  the  knee  occurring  in  exten- 
sion of  the  leg.  The  apparatus  also  is  arranged  by  a  stop  joint  at  the 
knee  to  prevent  complete  extension  of  the  knee.  It  consists  of  an  out- 
side upright  attached  to  the  boot  and  reaching  to  the  upper  part  of  the 

1  N.  Y.  Med.  Record,  April  20th,  1895. 

'2  Unreported. 

sTrans.  Am.  Orth.  Assn.,  vol.  viii.,  p.  227. 

4Ibid.,  vol.  viii.,  p.  237. 

5  Annals  of  Surg.,  1899. 

6N.  M.  Shaffer:  Read  before  College  of  Phys.,  Philadelphia,  March  11th.  1898. 


352  ORTHOPEDIC    SURGERY. 

thigh,  and  an  inside  upright  reaching  from  the  upper  thigh  to  the  upper 
part  of  the  calf,  and  a  pad  is  placed  over  the  inner  aspect  of  the  knee. 
The  object  of  this  treatment  is  by  preventing  harmful  motions  and  posi- 
tions for  some  months  to  produce  a  reunion  of  the  cartilage  to  its  proper 
attachments  and  a  return  of  the  ligamentum  patellae  to  its  proper  length. 

Trigger  Knee. 

The  so-called  trigger  knee,  described  also  as  genou  a  ressort  or  schnel- 
lendes  Knie,  is  characterized  clinically  by  a  disturbance  in  extension  of 
the  leg.  Extension  is  normal  until  about  1(50°  is  reached,  is  then  com- 
pleted with  a  snap  and  forcible  jerk,  during  which  there  is  also  outward 
rotation  of  the  tibia.  It  is  not  connected  with  any  disease  of  the  knee- 
joint  nor  any  obvious  abnormality  save  looseness  of  the  ligaments.  The 
cause  is  evidently  a  disturbance  of  the  movement  of  the  semilunar  carti- 
lages, particularly  the  external,  which  is  caught  between  the  joint  sur-: 
faces  and  suddenly  freed,  producing  the  jerk  described.  The  prognosis 
in  children  is  good,  depending  upon  tightening  of  the  ligamentous  struc- 
tures with  or  without  treatment.  Mechanical  treatment  is  apparently 
not  necessary,  at  least  in  children.1 

Symptomatic  Affections  of  the  Knee-Joint. 

Certain  malpositions  of  the  foot  may  result  in  pain,  irritation,  and 
even  synovitis  of  the  knee-joint,  when  the  knee  structurally  is  normal 
and  affected  only  secondarily.  Such  disturbances  occur  in  flatfoot,  pro- 
nated  foot,  and  shortening  of  the  gastrocnemius  muscle.  The  mechanism 
of  their  production  has  been  worked  out  by  Dane.  The  consideration  of 
this  subject  will  be  taken  up  later. 

JRupture  of  the  quadriceps  extensor  femoris  may  occur  either  above  or 
below  the  patelia.  Loss  of  the  power  of  extension  of  the  leg  at  Once 
results.  Recovery  without  operation  is  slow  and,  as  a  rule,  incomplete. 
Suture  of  the  separated  ends  is  indicated. 

1  Trans.  Am.  Orth.  Assn.,  vol.  x.,  p.  40  ;  Tkiein  :  Monatsch.  f.  Unfallkh.,  1896,  p. 
182;  Rolen:  Ibid.,  1898,  377;  Nasse:  Deutsche  Chir.,  Lief.  66,  Heft  1,  p.  299;  Cot- 
ton :  Journal  Boston  Society  Medical  Sciences,  May,  1899. 


CHAPTER  IX. 

DISEASES    OF    THE    JOINTS    OF    THE    ANKLE    AND    FOOT. 

Ankle. — Synovitis. — Tuberculosis. — Tenosynovitis.  —  Functional     affections.  —  Meta- 
tarso-phalangeal  articulations. 

Diseases  of  the  Ankle- Joint. 

Synovitis. — Acute  synovitis  of  the  ankle-joint  is  common,  most  often 
as  the  result  of  injury  and  rheumatism.  Owing  to  the  anatomical  rela- 
tion of  the  parts,  effusion  within  the  joint  can  take  place  only  to  a  lim- 
ited extent.  Peri-articular  swelling  is  a  marked  and  early  symptom,  be- 
cause of  the  fact  that  the  soft  parts  next  the  joint  are  not  hidden  under 
a  thick  layer  of  muscle  or  fat. 

In  simple  chronic  synovitis  the  foot  may  be  held  extended  beyond  a 
right  angle,  and  at  the  tibio-tarsal  angle  in  front  more  or  less  prominence 
is  found  when  the  capsule  is  distended  with  fluid.  This  is  limited  above 
and  below,  and  sometimes  the  swelling  can  be  seen  to  have  raised  the 
anterior  tendons,  and  it  is  sometimes  possible  to  detect  fluctuation  here. 
There  is  also  likely  to  be  a  slight  swelling  at  the  sides  of  the  tendo 
Achillis.  In  simple  chronic  synovitis  motion  is  generally  but  little 
limited  and  not  very  painful,  or  but  slightly  so,  so  that  a  weakness  and 
stiffness  of  the  joint  with  occasional  pain  are  the  only  symptoms  com- 
plained of. 

.     The  tendons  and  ligaments  are  usually  involved  in  severe  sprains  of 
the  ankle. 

Acute  traumatic  synovitis  of  the  ankle  is  treated  either  by  rest  and 
fixation,  by  massage,  or  by  hot-air  baths  or  by  a  combination  of  these. 

When  walking  is  painful  in  the  convalescent  stages  or  when  the 
sprain  has  become  chronic,  it  is  desirable  to  support  the  arch  of  the  foot 
in  the  manner  to  be  described  in  speaking  of  affections  of  the  foot.  Flat- 
foot  at  times  results  from  sprains  of  the  ankle. 

Chronic  synovitis  is  most  likely  to  be  the  result  of  the  acute  condition 
which  for  some  reason  has  not  been  properly  recovered  from.  In  cases 
of  long  standing  the  circulation  and  innervation  of  the  foot  and  leg  be- 
come impaired  and  swelling  and  congestion  occur  in  connection  with 
pain,  tenderness,  and  impaired  use.  Malpositions  of  the  foot  may  occur, 
the  most  common  being  a  limitation  of  dorsal  flexion.  Under  these  cir- 
23 


354 


ORTHOPEDIC   SURGERY. 


cumstances  the  dorsal  "flexibility  must  be  restored,  the  arch  of  the  foot 
supported,  and  measures  employed  to  stimulate  the  circulation  aud  re- 


FiG.  314.— Tuberculous  Ankle-joint.  Diffuse  tuberculosis  of  tarsus.  Primary  focus  lost  in  the  area 
of  destruction,  a.  Tuberculous  infiltration  of  soft  parts;  b,  tuberculous  softening  of  tarsal  bones. 
(Nichols.) 

store  it  to  its  normal  condition.  Among  these  measures  may  be  men- 
tioned as  most  important  the  gradual  resumption  of  the  use  of  the  foot 
under  proper  protection. 

Chronic  Tuberculous  Disease. — The  seat  of  the  disease  may  be  in  the 
articular  end  of  the  tibia  or  in  the  astragulus;   and  other  adjacent  bones 


t-j. 


m    ;i 

- 

Fig.  315.— Tuberculous  Ankle,    o,  Lower  end  of  tibia ;  b,  tuberculous  cavity  in  tibia ;  c,  tuberculous  dis- 
ease of  calcis ;  d,  tuberculous  disease  of  astragalus.    (Nichols.) 

may  be  involved  secondarily  or  simultaneously,  as  the  os  calcis,  the 
scaphoid,  cuboid,  and  cuneiform  bones.  Affection  of  these  latter  bones 
may  also  exist  alone. 


DISEASES   OF   THE    JOINTS    OF    THE    ANKLE    AND    FOOT.        355 


The  affection  is  not,  as  a  rule,  a  painful  one,  but  in  certain  cases  it 
may  assume  this  type,  and  night  cries  may  accompany  an  exquisite  ten- 
derness of  the  whole  joint  to  pressure  and  motion.  Tenderness,  as  a 
rule,  is  present  over  the  joint  capsule  in  front,  and  perhaps  under  the 
malleoli,  and  swelling  and  heat  are  invariable  accompaniments  of  the 
affection.      Muscular  rigidity  is  marked  in  most  cases. ' 

Lameness  is  an  early  and  a  marked  symptom.  Sometimes  it  is  pro- 
duced by  the  pain  which  weight-bearing  causes  in  walking,  but  more 


FIG.  316.— Tuberculous    Disease   of 
tbe  Ankle. 


Fig.  317.— Ankle-joint  Disease  at  an  Early  Stage. 


often  by  the  muscular  stiffness  which  will  not  allow  the  ankle-joint  to 
bend.  .The  swelling  consists  of  a  boggy  infiltration  of  the  soft  parts 
around  the  ankle,  along  with  a  distention  of  the  joint  capsule  by  gelat- 
inous granulations.  In  character  it  is  cedematous.  This  swelling  is  uni- 
form around  the  ankle,  except  when  an  abscess  is  pointing  on  one  side. 
The  depressions  in  the  contour  of  the  ankle  in  front  and  behind  the  mal- 
leoli disappear  in  the  swelling.  The  foot  in  affections  of  the  ankle-joint 
usually  assumes  a  position  with  the  toes  pointing  downward,  and  in 
chronic  cases  -with  the  foot  slightly  rolled  outward  (in  the  position  of 
equino-valgus) .  This,  however,  is  not  the  only  malposition,  for  the  foot 
may  assume  the  position  of  pure  talipes  calcaneus.  These  malpositions 
are  brought  about  by  the  abnormal  tonic  muscular  contraction,  and  these 
deformities  yield  of  themselves  and  the  foot  returns  to  its  normal  position 
when  the  irritation  is  quieted  in  the  joint  by  proper  treatment. 


Annals  of  Anat.  and  Surg.,  May,  1882. 


356 


ORTHOPEDIC   SURGERY. 


Wasting  of  the  thigh  and  calf  muscles  occurs.     Abscess  may  occur. 

When  the  disease  attacks  the  medio-tarsal  or  tarso-metatarsal  joints, 
the  anterior  part  of  the  instep  appears  swollen  and  is  hot  and  tender. 
Motion  at  the  ankle  is  but  little  restricted,  but  motion  in  the  anterior 
part  of  the  foot  is  attended  by  pain  and  is  usually  lost.  The  location 
of  the  affection  is  evident  from  examination.     If  the  os  calcis  is  attacked 


Fig.  318.— Swelling  of  the  Joint  in  Disease  of  the  Ankle. 


primarily  it  is  manifested  by  the  same  symptoms  of  local  inflammation 
without  any  symptoms  referable  to  the  ankle-joint.  In  many  cases  the 
treatment  is  too  soon  discontinued  after  sprains,  and  a  teno-synovitis  or 
subacute  inflammation  of  part  of  the  synovial  sac  may  persist,  and  be 
accompanied  by  local  heat  and  tenderness.  It  matters  not  so  much  how 
long  after  a  sprain  is  found  in  the  ankle-joint,  local  heat  is  a  most  impor- 
tant sign ;  it  indicates  the  need  of  rest. 

The  recognition  of  disease  of  the  ankle  is  dependent  on  the  usual  symp- 
toms of  limping,  limitation  of  motion  of  the  joint,  stiffness,  swelling  of 
the  joint,  pain,  heat,  and  tenderness.  The  prominence  of  these  symp- 
toms varies  with  the  activity  and  extent  of  the  disease. 

Tenosynovitis  gives  rise  to  swelling  around  the  tendons ;    there  may 


DISEASES    OF   THE    JOINTS   OF   THE    ANKLE    AND    FOOT.         357 

be  some  puffiness  of  the  skin,  heat,  hyperesthesia,  and  pain  on  certain 
movements  of  the  foot;  but  extreme  change  in  contour  of  the  ankle  is  not 
present,  and  the  pain  is  chieHy  that  of  apprehension.  In  manipulating 
the  foot,  a  creaking  at  the  painful  spot  may  be  felt,  and  this  spot  itself 
is  sharply  localized  and,  as  a  rule,  is  not  over  the  joint,  but  in  the  course 
of  the  tendons. 

Functional  Affections. — The  most  troublesome  affections  to  diagnosti- 
cate from  ankle-joint  disease  are  the  functional  affections  which  result 


Fir.  319.— Tuberculous  Ankle.    Advanced  Stage. 

often  from  sprains  and  injuries.  Here  it  is  not  uncommon  to  find,  in 
hypersensitive  women  chiefly,  a  limitation  of  motion  of  the  ankle,  with 
much  pain  on  manipulation  and  pressure;  there  may  be  slight  'swelling 
left  over  from  the  injury,  and  the  question  to  be  decided  is,  whether  any 
disease  of  the  joint  exists  which  can  well  be  made  worse  if  the  patient 
goes  about,  or  if  it  is  purely  a  subjective  affair  which  can  be  overcome  by 
judicious  management.  In  one  case  rest  is  indicated,  in  the  other  activ- 
ity. The  diagnosis  of  functional  joint  disease  is  considered  in  full  in  the 
proper  place. 

Again,  it  should  be  repeated,  that  one  must  depend  chiefly  upon  the 
existence  of  the  objective  signs  of  ankle  disease,  rather  than  upon  the 
patient's  feelings;  allowing,  however,  due  weight  to  the  history  of  the 
affection  and  the  patient's  sex  and  constitution. 

Treatment. — The  general  principles  of  the  treatment  of  chronic  joint 
disease  are  nowhere  more  applicable  than  in  ankle-joint  disease,  although 
they    are,    of    course,    modified   by  the  anatomical   conditions    present. 


S58 


ORTHOPEDIC    SURGERY. 


'fraction  is  not  applicable  as  a  mode  of  treatment,  from  the  difficulty  of 
applying  it,  so  that  one  turns  to  fixation  and  protection. 

Protection  from  jar  is  especially  indicated — as  will  be  readily  seen, 
if  it  be  borne  in  mind  that  in  locomotion  the  whole  weight  of  the  body  is 
borne  at  each  step  upon  the  comparatively  small  surface  of  the  articulat- 
ing portion  of  the  astragulus.  Fixation  of  the  ankle  in  a  stiff  bandage 
while  allowing  the  patient  to  walk  upon  the  limb  is  a  manifest  error,  as 
affording  little  or  no  real  protection  to  the  joint.  Fixation  is  of  advan- 
tage in  the  more  acute  stages  of  the 
affection,  and  is  readily  furnished  by 
means  of  stiff  bandages.  A  plaster-of- 
Paris  bandage  is  the  most  convenient 
appliance,  and  should  be  carried  above 
the  knee  so  as  to  fix  that  joint  also. 
Silicate  and  dextrin  bandages  are  more 
durable,  but  more  complicated  in  their 
application.  Protection  can  be  fur- 
nished either  by  means  of  crutches  or, 
more  thoroughly,  by  means  of  protect- 
ive splints  with  perineal  supports. 
Protective  splints,  described  for  the 
knee-joint,  are  useful  in  ostitis  of  the 
ankle.  The  Thomas  knee-splint  is 
generally  the  most  available. 

Unless  the  disease  is  far  advanced, 
children  who  are  in  good  condition,  as 
a  rule,  do  well  under  conservative 
treptment.  Adults  do  not  make  such 
good  progress ;  but  conservatism  should 
first  be  tried.  If  abscesses  form,  they 
should  be  incised  and  traced  to  their 
source,  and  if  loose  bone  is  detected 
this  should  be  removed.  If  the  foot  assumes  a  malposition,  this  should 
be  corrected ;  and  this  is  best  done  by  applying  a  plaster  bandage  to  the 
foot  in  its  malposition  and  quieting  thereby  the  inflammation  so  much 
that  in  two  weeks  the  malposition  will  be  found  less  and  an  improved 
position  can  be  gained.  The  general  health  should  be  carefully  inquired 
into  and  appropriately  treated.  All  these  procedures  may  be  grouped 
together  and  be  said  to  complete  the  expectant  method  of  treatment. 

In  a  series  of  thirty  cases  of  ankle-joint  disease  treated  conservatively 
observed  by  Gibney 1  the  results  were  as  follows : 
The  minimum  duration  of  the  disease  was  1  year. 


Fig.   320.— Fixation   Ankle   Shoe.    (Chil- 
dren's Hospital  Report.) 


1  "NT.  Y.  Med.  Rec,  August  21st,  1880,  p.  19?  I  Am.  Jour,  of  Obstet..  1880.  p.  434. 


DISEASES   OP   THE   JOINTS   OP   THE   ANKLE   AND   FOOT.        359 

The  maximum  duration  of  the  disease  was  6  years. 

The  average  duration  of  the  disease  was  3  years  and  3  months. 

The  average  time  of  treatment  was  1  year  and  3  months. 

In  19  cases  suppuration  was  very  extensive. 

In  6  cases  suppuration  was  moderate. 

In  5  cases  suppuration  was  absent. 

The  disease  occurred  in  young  children,  the  limbs  were  slightly  short- 
ened, and  the  calf  was  atrophied.  Twenty  patients  did  not  limp  at  all, 
and  7  only  slightly.  There  were  one  or  two  cases  in  which  some  defor- 
mity appeared  in  the  foot  after  use. 

The  expectant  plan  fully  carried  out  is  justifiable  in  a  large  proportion 
of  cases,  and  on  the  whole  the  results  obtained  are  good.  In  cases  of 
tuberculous  disease  of  the  ankle  the  decision  of  continuance  of  conserva- 
tive treatment  or  the  adoption  of  operative  interference  is  one  which  is 
based  largely  upon  the  patient's  age  and  the  circumstances  of  attendant 
care. 

There  are  three  alternatives  left  if  the  expectant  method  fails.  The 
mildest  form  of  operative  interference  consists  in  curetting  the  sinuses 
and  removing  what  diseased  bone  it  is  possible  to  reach.  Occasionally 
it  may  be  possible  to  scrape  out  a  focus  of  tuberculous  material  in  the  os 
calcis,  but  in  the  tarsus  proper  it  is  rarely  a  satisfactory  procedure.  The 
second  operation  is  a  formal  excision  of  the  diseased  bones.  The  third 
and  most  radical  measure  is  amputation  of  the  leg  or  foot. 

Culbertson  brought  all  excision  records  up  to  1873.  He  tabulates  124 
cases  excised  for  disease.  Of  these,  perfect  results  were  obtained  in 
5.55  per  cent.  A  useful  foot  in  60.18  per  cent,  and  2.77  per  cent  were 
not  useful,  and  it  was  necessary  to  amputate  the  foot  in  12.03  per  cent  of 
the  cases.  The  mortality  table  states  that,  of  the  124  cases,  about  8.5 
per  cent  died  from  the  operation. 

Culbertson's  cases  were  reported  before  the  days  of  antiseptic  surgery. 
The  long  time  then  necessary  for  healing  of  the  operation  wound  is, 
under  present  methods  of  wound  treatment,  much  shortened,  and  sup- 
puration is  infrequent.  Cases  are  being  reported  to-day  with  great  accu- 
racy and  in  fuller  detail.  Hence  the  great  value  to  be  attached  to  the 
reports  of  Connor's  108  cases.  He  found  that  in  10.53  per  cent  there 
were  failures;  6.32  per  cent  could  walk  with  a  cane;  24.21  per  cent 
could  walk  and  not  limp;  and  47.37  per  cent  had  good  results.  The 
foot  is  shortened  and  broadened;  the  ankle  motions  vary.  The  short- 
ening of  the  limb  varies,  but  is  slight.  In  a  few  cases  an  osseous  regen- 
eration occurs.  Connor  finds  that  an  excision  of  the  whole  or  part  of 
the  tarsus  is  not  much  more  dangerous  than  an  ankle-joint  amputation, 
and  subsequent  removal  of  the  foot  is  possible  if  desired. 

A  series  of  eighteen  excisions  of  the  ankle-joint  was  reported  by 
Scudder.     These  were  hospital  cases  operated  on  at  the  Children's  Hos- 


360  ORTHOPEDIC   SURGERY. 

pital  and  were  cases  in  which   the  ultimate  result  was  known.     They 
were  reported  in  lSs'.).1 

The  question  arises,  Will  the  disease  in  the  foot  cease  if  the  bone  is 
removed?  It  may  be  said  that,  if  thoroughly  removed  in  children,  re- 
lapse is  unlikely  to  occur.  More  relapses  occur  from  partial  operations 
and  from  gougings  and  scrapings  than  from  any  other  cause.  The  earlier 
excision  is  done,  and  the  more  bone  removed  from  the  tarsus,  the  better 
is  the  result. 

The  operation  should  be  performed  by  the  subperiosteal  method ;  the 
diseased  tissue  removed  from  the  ends  of  the  leg  bones  and  the  astragalus 
removed  entire  with  the  top  of  the  os  cacis,  if  diseased. 

There  are  many  modifications  of  the  lateral  incisions  which  are  in 
common  use,  and  other  incisions  radically  differing;  but  of  all  methods 
preference  must  be  given,  in  the  opinion  of  the  writers,  to  that  of  Kocher, 
which  has  proved  eminently  satisfactory  in  their  experience  when  a 
formal  excision  is  to  be  done. 

The  method  is  as  follows ;  The  foot  is  held  at  a  right  angle  and  a 
superficial  incision  is  made  along  the  outer  border  just  below  the  external 
malleolus,  reaching  from  the  tendo  Achillis  to  the  extensor  tendons. 
The  peroneal  tendons  are  dissected  out,  secured  by  sutures,  and  then  cut 
by  a  second  and  deeper  incision.  The  ankle-joint  is  opened  very  easily 
and  the  capsule  along  the  anterior  and  posterior  surfaces  of  the  tibia  is 
cut.  The  foot  is  then  dislocated  inward  as  far  as  is  desired,  and  the 
joint  can  be  inspected  to  any  extent.  After  the  diseased  parts  have  been 
removed,  the  foot  is  reduced  to  its  proper  position,  the  peroneal  tendons 
are  united,  and  the  wound  is  closed. 

"When  the  foot  is  dislocated,  an  admirable  view  is  obtained  of  the  in- 
terior of  the  joint. 

The  osteoplastic  resection  of  Mikulicz2  is  a  substitute  for  amputation 
in  cases  of  very  serious  disease  of  the  posterior  bones  of  the  foot. 
*  The  after-treatment  of  cases  of  ankle-joint  excision  is  similar  to  the 
treatment  of  the  others  spoken  of.  Asepsis,  and  immobilization  in  a 
correct  position  are  the  requirements;  and  to  this  end  infrequent  dress- 
ings are  very  desirable.  Plaster  of  Paris  applied  outside  of  a  heavy 
dressing  is  very  serviceable,  as  in  knee-joint  excision.  An  accurate  and 
equally  efficient  splint  is  a  wire  posterior  splint,  which  is  made  of  a  rod 
of  '•  copper-washed  iron  wire  "  three-sixteenths  of  an  inch  in  diameter, 
which  is  bent  to  fit  the  leg  and  padded  except  at  the  ankle,  where  it  is 
covered  with  rubber  tubing  and  can  be  rendered  aseptic  and  incorporated 
in  the  dressing  there.  The  rest  of  the  splint  is  padded.  One  can  also 
use  an  anterior  wire  splint.     But  whatever  splint  is  used,  the  point  about 


1  Scudder:  Orth.  Trans.,  vol.  ii.,  p.  53. 

-  Arcliiv  f.  klin.  Chir.,  xxvi.  ;  Med.  News,  December  3d,  1887 


DISEASES   OF   THE   JOINTS   OP  THE   ANKLE    AND    FOOT.        tttil 


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362  ORTHOPEDIC   SURGERY. 

which  one  must  be  most  oareful  is  to  see  that  the  foot  is  at  a  right  angle 
to  the  leg  and  in  the  same  plane.  For  a  long  time  after  excision  the 
joint  should  be  protected  from  weight-bearing  by  the  application  of  a 
Thomas  splint,  or  some  such  appliance. 

Metatarso-Phalangeal  Articulations. — These  joints  are  occasionally 
attacked  as  a  result  of  injury.  In  chronic  rheumatoid  arthritis  they 
may  also  be  attacked.     Inflammation  of  the  metatarso-phalangeal  articu- 


Fig.  321.—  Form  of  Wire  Splint  for  Treatment  of  the  Ankle  after  Excision. 

lation  of  the  great  toe  takes  place  consequent  on  the  distortion  of  the  toe 
called  "hallux  valgus  or  in-toe,"  the  result  of  imperfect  shoes,  and  also 
secondarily  to  the  affection  well  known  as  bunion.  An  ankylosis  of  this 
joint  occurs  in  adolescents,  probably  a  sequel  to  a  long-continued  subacute 
inflammation,  the  result  also  of  imperfect  shoes. 

Nothing  especial  need  be  said  of  inflammation  of  the  phalangeal 
articulations,  except  that  they  are  not  common.  Excision  of  the  smaller 
joints  of  the  foot  is  rarely  required.  When  it  is  necessary,  however,  it 
is  done  by  any  simple  method  which  seems  applicable. 


CHAPTER  X. 

DISEASES    OF    THE    OTHEE    JOINTS. 

Shoulder-joint.  —  Acute  synovitis.  — Chronic  synovitis.  —Chronic  tuberculous  dis- 
ease.—Bursitis  and  teno-synovitis. — Chronic  rheumatoid  arthritis. — Peri-ar- 
thritis.— Charcot's  disease.— Synovial  cysts. — Bursitis. — Treatment. — Excision 
of  the  shoulder-joint. — Habitual  or  recurrent  dislocation. — Obstetrical  paraly- 
sis.— Diseases  of  the  elbow. — Synovitis.— Chronic  tuberculous  disease. — Stiffness 
of  the  elbow. — Treatment. — Excision  of  the  elbow. — Arthrectomy. — Diseases 
of  the  wrist. — Synovitis. — Tuberculous  disease. — Teno-synovitis. — Chronic 
arthritis  deformans. — Treatment. — Excision  of  the  wrist. — Sacro-iliac  disease. 
— Pathology. —  Etiology. —  Symptoms. —  Diagnosis. — Prognosis. —  Treatment. — 
Diseases  of  the  phalangeal  articulations.  — ■  Diseases  of  the  temporu  -  maxillary 
articulations. — Diseases  of  the  sterno-clavicular  and  acromio-clavicular  joints. 
— Diseases  of  the  articulations  of  the  sternum. — Diseases  of  the  symphysis  pubis. 

Diseases  of  the  Shoulder-Joint. 

Acute  synovitis  of  the  shoulder  occurs  as  the  result  of  injury,  rheu- 
matism, etc.  The  physical  signs  of  the  affection  do  not  differ  essentially 
from  those  described  in  speaking  of  other  joints.  The  acute  arthritis  of 
infants  is  occasionally  observed  in  this  joint,  where  it  presents  its  usual 
characteristics. 

Chronic  synovitis  of  the  shoulder  is  an  affection  existing  either  as  a 
sequel  of  an  acute  attack,  the  result  of  some  injury,  or  as  a  slow,  per- 
sistent process,  beginning  with  slight  symptoms  easily  disregarded. 

The  earliest  symptom  to  attract  notice  is  stiffness,  observed  particu- 
larly in  forced  movements,  as  in  placing  the  hand  on  the  head,  etc.  Pain 
is  a  variable  symptom. 

A  slight  fulness  about  the  joint  may  be  detected  at  this  time,  the 
humero-pectoral  groove  being  indistinct,  and  the  depression  below  the 
acromion  obliterated.  Although  an  increase  of  surface  temperature  may 
often  be  detected,  its  absence  is  of  little  importance,  the  joint  being  so 
thoroughly  covered.  As  the  disease  progresses,  the  case  presents  an  ex- 
aggeration of  the  early  symptoms ;  motion  becomes  more  restricted,  swell- 
ing increases  as  effusion  takes  place,  the  shoulder  appearing  broader, 
and  elevations  may  replace  the  natural  depressions.  Atrophy  of  the  del- 
toid and  scapular  muscles  gradually  occurs,  but  to  a  less  extent  than  in 
the  forms  of  ostitis.     Pain  is  a  symptom  of  varying  severity.     In  gen- 


;»u 


ORTHOPEDIC    SURGERY 


\ 


eral,  the  tendency  is  toward  resolution  with  more  or  less  impairment  of 
joint  motion. 

Chronic  bursitis  and  tenosynovitis  may  exist  and  simulate  closely 
chronic  synovitis  of  the  shoulder.  But  the  stiffness  is  in  the  former  only 
in  the  direction  of  certain  movements,  and  the  tenderness  and  swelling 
are  chiefly  confined  to  the  affected  structures. 

Chronic  Tuberculous  Disease — The  general  symptoms  of  ostitis  of  the 
shoulder  differ  in  no  way  from  those  in  the  usual  for  mof  this  disease 

in  other  more  commonly  affected 
joints,  except  that  stiffness  of  the 
joint  and  malpositions  due  to  mus- 
cular spasm  are  less  noticeable  on 
account  of  mobility  of  the  scapula. 
The  disease  is  insidious,  extremely 
chronic,  prone  to  suppuration,  and 
decided  impairment  of  the  joint  is 
likely  to  result. 
\  One  of  the  earliest  signs  of  this 

\  disease   is    pain    of   a   dull  aching 

\  character,  which  is  usually  aggra- 

vated  at    night,    and    is    referred 
v3^_  either  to  the  joint  itself,  or  to  the 

middle  of  the  arm  near  the  inser- 
tion of  the  deltoid.  In  many  cases 
this  symptom  is  absent  or  very 
slight.  A  slight  increase  of  sur- 
face temperature  may  be  detected, 
but  the  thickness  of  the  coverings 
of  the  shoulder-joint  renders  this 
uncertain.  There  will  usually  be 
found  a  tenderness,  frequently  lo- 
calized over  a  small  area,  generally 
over  the  anterior  surface  of  the 
joint,  but  sometimes  on  its  posterior  aspect.  The  patient  instinctively 
holds  the  arm  at  rest,  and  attempts  at  passive  motion  provoke  muscular 
spasm,  and  if  the  attempt  is  persisted  in  the  humerus  and  scapula  are 
seen  to  move  together.  The  stiffness  of  the  arm  along  with  the  swelling 
are  the  most  characteristic  features  of  the  affection.  Early  in  the  dis- 
ease a  change  in  contour  of  the  joint  becomes  apparent,  which  is  due  to 
enlargement  of  the  head  of  the  humerus  as  well  as  to  muscular  atrophy. 
When  the  swelling  is  due  to  effusion  within  the  joint,  the  shoulder  ap- 
pears fuller  and  broader  than  normal,  and  this  is  seen  best  in  looking 
down  on  the  patient;  the  natural  depressions  in  front  of  and  behind  the 
joint  become  either  obliterated  or  are  the  sites  of  prominences. 


I 


' •    . 

Fig.  322.— Shortening  of  Humerus;  Lack  of  Growth 
from  Early  Epiphysitis.    (W.  P.  Bolles.) 


DISEASES   OF  TEE   OTHER  JOINTS.  365 

If  suppuration  occurs,  the  patient  complains  more  of  pain,  and  the 
swelling  increases.  The  prominence  of  the  swelling  will  depend  en  the 
direction  taken  by  the  pus,  but  this  will  most  often  be  found  collected  in 
the  axilla,  under  the  deltoid,  or  along  its  anterior  edge.  The  subsequent 
course  is  slow,  the  result  depending  on  the  extent  of  the  degenerative 
process,  which  may  terminate  soon  after  evacuation  of  the  pus  or  con- 
tinue to  complete  destruction  of  the  head  of  the  humerus. 

The  possible  results  are:  recovery  with  a  stiff  joint  (ankylosis),  de- 
formity and  impaired  muscular  power,  or  entire  destruction  of  the  head 
of  the  bone;  and  in  children  later  arrest  of  development  of  the  humerus 
may  result  (Fig.  322). 

Chronic  Rheumatic  Arthritis. — Next  to  the  knee  the  shoulder  is  the 
most  frequent  seat  of  this  disease,  when  it  occurs  in  the  monarticular 
form. 

When  one  shoulder  alone  is  affected  the  history  of  injury  is  usual, 
but  in  the  polyarticular  forms  this  is  not  so  common. 

The  disease  may  first  manifest  itself  to  the  patient  as  a  slight  attack 
of  joint  pain,  tenderness,  and  stiffness,  and  from  this  condition  pass  into 
the  slow  chronic  course,  with  occasional  exacerbations,  or  it  may  begin 
insidiously.  The  amount  of  pain  varies :  it  is  more  or  less  persistent,  but 
not  constant,  and  is  dull  and  heavy  and  usually  worse  at  night.  Stiffness 
appears  at  this  time  with  pain,  at  first  only  slight,  and  noticed  in  forced 
movements,  when  the  arm  is  raised  above  the  level  of  the  shoulder.  Both 
pain  and  stiffness  are  more  noticeable  after  a  period  of  rest. 

From  the  appearance  of  these  symptoms  the  disease  is  slow,  extend- 
ing over  months  or  more  before  marked  change  occurs.  As  the  disease 
progresses  the  muscles  waste,  and  in  severe  cases  to  a  very  noticeable 
degree.  A  creaking  sensation,  both  on  active  and  passive  motion,  is  al- 
most always  found  by  placing  the  hand  over  the  joint.  Later  in  the  dis- 
ease, when  the  characteristic  osseous  changes  occur,  the  arm  can  be  raised 
but  a  short  distance  from  the  side,  and  the  loss  of  muscular  power  is 
great.  Swelling  independent  of  bone  enlargement  sometimes  occurs,  and 
is  due  to  effusion  within  the  cavity  of  the  synovial  membrane,  but  is  not 
a  common  occurrence  and  usually  appears  late  in  the  disease.  When 
the  changes  in  the  joint  have  taken  place  a  characteristic  appearance  of 
the  joint  is  found.  The  head  of  the  humerus  is  more  prominent  in  front 
of  the  joint,  while  behind  is  a  depression  as  if  the  head  of  the  bone  was 
displaced  forward,  while  the  shoulder  droops. 

Peri-arthritis  of  the  Shoulder.- — -Duplay  has  described  as  peri-arthritis 
of  the  shoulder- joint  a  condition  of  stiffness  not  infrequently  seen  after 
comparatively  slight  injuries.  Pain  accompanies  motion  beyond  a  cer- 
tain limit.  Atrophy  of  the  muscles  is  present,  and  at  times  there  is 
some  spontaneous  pain.  The  arm  may  become  of  comparatively  little 
use.     The  diagnosis  of  peri-arthritis  is  not  based  on  pathological  evidence, 


366  ORTHOPEDIC   SURGERY. 

and,  judging  from  clinical  analogy,  it  seems  fair  to  infer  that  the  affec- 
tion may  either  be  a  bursitis  or  may  include  the  synovial  membrane,  con- 
stituting a  chronic  synovitis  as  well  as  a  peri-arthritis. 

Gonorrhoea!  Synovitis. — The  shoulder  is  not  infrequently  the  seat  of 
urethral  arthritis,  but  this  differs  in  no  way  in  its  course  and  symptoms 
from  the  same  disease  in  the  mere  commonly  affected  joints. 

Charcot's  disease  occurring  in  the  shoulder-joint  is  less  common  than 
at  the  hip,  knee,  or  elbow,  but  it  presents  no  especial  characteristics  in 
this  situation,  except  that  the  head  of  the  humerus  and  the  glenoid  cavity 
may  be  worn  away ;  the  latter  in  such  a  manner  as  to  form  a  large  hollow 
cavity. 

Synovial  cysts  may  rarely  be  noted  in  connection  with  the  shoulder ; 
bursitis  and  enlargement  of  the  bursa  beneath  the  deltoid  and  other  bursae 
about  the  shoulder  may  occasionally  be  seen. 

Treatment. — In  synovitis  of  the  shoulder-joint  with  any  active  inflam- 
mation, the  indication  is  simply  for  rest  and  fixation.  These  are  readily 
secured  by  means  of  a  sling  and  a  bandage  securing  the  arm  to  the  side. 
It  is  important  to  mention  that  in  chronic  synovitis  of  the  shoulder  the 
weight  of  the  arm  dragging  upon  the  joint  structures  may  be  a  factor  in 
keeping  up  the  pain  and  irritation.  Consequently  in  the  shoulder  the  use 
of  a  supporting  sling  is  necessary  in  these  cases.  Compression  will  be 
needed  if  there  are  swelling  and  effusion.  Fixation  should  not  be  con- 
tinued longer  than  there  is  subacute  inflammation,  and  can  be  gradually 
discontinued ;  first  discarding  the  bandage  and  retaining  the  sling,  which 
can  be  discontinued  later.  So  long  as  muscular  irritability  exists,  rest  is 
indicated.  In  these  cases  an  increased  arc  of  motion  and  diminished 
sensitiveness  will  usually  follow  a  few  days'  rest  of  the  joint,  and  perma- 
nent ankylosis  is  rendered  less  likely  by  the  application  of  timely  immo- 
bilization. 

In  tuberculous  ostitis  at  the  shoulder- joint,  the  indications  for  treat- 
ment are  practically  the  same  as  those  presented  in  chronic  synovitis. 
Distraction  is  not  indicated  in  disease  of  the  shoulder,  as,  owing  to  the 
laxity  of  the  joint,  the  weight  of  the  dependent  arm,  if  kept  at  rest,  is 
sufficient  to  separate  the  humerus  from  the  opposing  bone  surface  of  the 
scapular  articulation.  In  painful  cases,  however,  it  might  be  necessary 
to  apply  traction  for  a  time,  by  an  instrument  similar  to  the  short  Say  re 
splint  figured  for  hip  disease,  or  even  by  the  weight  and  pulley  traction 
applied  during  recumbency. 

Monks  has  called  attention  to  the  advantage  sometimes  to  be  derived 
from  supporting  the  shoulder  in  a  position  at  right  angles  to  the  side  of 
the  body.  This  method  may  be  of  advantage  by  taking  the  weight  of  the 
upper  extremity  off  of  the  shoulder,  it  relaxes  the  deltoid  and  other 
structures  covering  the  joint,  and  the  circumflex  nerve  and  other  deeply 
seated  structures  are  relieved  from  pressure.     The  arm  is  either  held  in 


DISEASES   OF   THE   OTHER   JOINTS.  367 

this  position  by  a  plaster-of-Paris  spica  bandage,  supporting  the  arm  and 
encircling  the  trunk,  or  a  platform  splint  may  be  constructed  of  wire, 
which  takes  its  base  of  support  from  the  side  of  the  trunk  and  supports 
the  arm  by  means  of  a  platform  running  out  from  this.  The  method  is 
of  advantage  in  certain  cases  in  which  the  ordinary  position  is  not  com- 
fortable. ' 

The  question  of  the  use  of  forcible  passive  motion  in  the  convalescent 
stage  does  not  differ  from  the  same  question  discussed  in  speaking  of 
other  joints.  If  the  stiffness  is  due  to  adhesions,  manipulation  under  an 
anaesthetic,  followed  by  massage,  etc.,  may  be  of  value;  but  in  the  major- 
ity of  light  cases  gradual  passive  exercises  will  suffice.  Gentle,  gradu- 
ated, passive  motion  carried  to  the  verge  of  being  painful,  with  the  use 
of  electricity,  is  of  great  advantage  in  many  cases  of  shoulders  stiffened 
from  a  slight  degree  of  chronic  joint  inflammation.  If  the  stiffness  above 
alluded  to  is  the  result  of  the  fixation  due  to  muscular  spasm,  forcible 
passive  motion  will  be  of  no  use,  as  the  reflex  spasm  will  reappear  after 
the  effect  of  the  anaesthetic  has  passed  away,  as  long  as  the  disease  of  the 
joint  remains. 

Local  applications  to  the  joint  are  to  be  used  at  the  shoulder- joint  for 
tne  same  reasons  and  indications  as  in  other  articulations. 

On  the  whole  the  results  of  the  conservative  treatment  of  tuberculous 
shoulder-joint  disease  are  satisfactory  except  in  the  case  of  persons  whose 
general  condition  is  decidedly  bad.  The  great  freedom  of  movement  of 
the  scapula  allows  many  arm  motions  to  take  place  without  any  move- 
ment of  the  head  of  the  humerus  in  the  glenoid  cavity,  so  that  it  is  easy 
to  secure  almost  complete  rest  to  the  affected  joint.  In  stiffness  resulting 
from  chronic  rheumatoid  arthritis  of  the  shoulder  forcible  manipulation 
is  harmful  and  useless  during  the  stages  of  joint  irritation.  After  the 
irritation  has  subsided  manipulation,  sometimes  forcible  under  an  anaes- 
thetic, and  sometimes  gentle,  is  of  value.  Along  with  the  latter  should 
be  used  massage,  electricity,  and  the  douche. 

Excision  of  the  Shoulder-Joint. — There  is  a  mortality  from  the  opera- 
tion of  about  fifteen  to  eighteen  per  cent. 

The  most  favorable  age  for  operation  appears  to  be  from  ten  to  twenty ; 
the  least  favorable  being  from  five  to  ten  years.  The  disease  is  rather  un- 
common in  young  children,  consequently  excisions  are  not  frequently  per- 
formed in  childhood.  The  prognosis  after  this  operation  is  good,  as  re- 
gards usefulness  of  the  arm ;  but  a  stiff  joint  should  be  avoided.  The 
movements  of  the  arm  are  usually  impaired  in  abduction  and  rotation; 
due  to  the  injury  done  the  deltoid,  and  the  cutting  of  the  attachments  of 
the  rotators  of  the  humerus. 

The  longitudinal  anterior  incision  is  in  general  the  most  useful  for 

'Boston  Med.  and  Surg.  Jour.,  August  21st,  1890. 


368  ORTHOPEDIC   SURGERY. 

excision  of  the  shoulder.  The  periosteum  is  divided  with  a  bone  knife, 
inserted  along  the  inner  border  of  the  bicipital  groove.  The  arm  is 
rotated  both  outward  and  inward,  and  the  periosteum  and  muscular  at- 
tachments are.  removed  as  they  appear.  The  head  can  be  removed  with 
the  keyhole  or  the  chain  saw,  removing  as  much  of  the  bone  as  is  dis- 
eased. The  operation  is  performed  subperiosteally  and  the  head  of  the 
bone  may  be  thrown  out  of  the  wound  and  thus  sawed  off.  In  after- 
treatment,  very  good  fixation  can  be  obtained  by  bandaging  the  arm  to 
the  side,  with  a  thick  pad  between  the  body  and  the  inner  side  of  the 
arm. 

Plaster-of -Paris  dressing  around  the  arm  and  chest  affords  the  best 
fixation ;  and  after  the  need  of  complete  fixation  is  passed,  a  sling  an- 
swers every  purpose. 

Passive  motion  of  the  joint  should  be  commenced  as  soon  as  possible 
after  the  operation,  if  it  is  desired  to  secure  a  movable  joint;  but  the 
surgeon  in  that  way  runs  the  risk  of  making  a  flail  joint,  inasmuch  as 
but  little  of  the  ligamentous  structure  has  been  preserved.  Ankylosis  of 
the  shoulder  is  of  comparatively  slight  importance  in  comparison  to  ob- 
taining a  stable  joint  on  account  of  the  mobility  which  the  shoulder-blade 
possesses,  so  that  passive  motion  should  not  be  begun  too  early  and  in 
many  cases  should  not  be  undertaken  at  all. 

Habitual  or  recurrent  dislocation  of  the  shoulder  becomes  at  times  an 
affection  requiring  orthopedic  treatment. 

The  name  "  habitual  dislocation "  should  refer  only  to  those  cases 
in  which  dislocation  occurs  from  causes  too  slight  to  displace  the  normal 
joint.  A  person  may  dislocate  one  shoulder  two  or  three  times  from  a* 
succession  of  severe  accidents  without  falling  into  this  special  pathologi- 
cal class.1  The  causes  of  the  condition  maybe  formulated  as  follows:  1. 
Laxity  of  the  capsule  of  the  joint.  2.  Partial  fracture  of  the  head  of  the 
humerus.  3.  Partial  fracture  of  the  glenoid  cavity.  4.  Tearing  away 
of  muscular  insertions  and  rupture  of  tendons.  5.  Abnormality  in  the 
shape  of.  the  head  of  the  humerus  not  demonstrably  due  to  fracture,  but 
probably  the  result  of  chronic,  non-suppurative  inflammation. 

It  would  seem  as  if  in  certain  instances  the  cause  of  the  recurrence  of 
the  dislocation  was  insufficient  immobilization  of  the  arm  after  a  primary 
dislocation. 

The  atrophy  of  certain  muscles  seems  to  be  characteristic  in  these 
cases  in  a  series  observed  by  one  of  the  writers.2 

Certain  of  the  muscles  of  the  affected  side  are  so  notably  atrophied 
and  flabby  that  they  at  once  attract  attention  on  examination.  The 
other  muscles  are  not  notably  smaller  than  those  of  the  other  side.     The 

1  Stimson :  "Dislocations,"  p.  265,  quoting  also  Gurlt,  "Path.  Anat.  der  Gelenk- 
krankheiten,"  p.  250;  dishing:  Med.-Chir.  Trans.,  1837,  p.  336. 
'^Burrell  and  Lovett:  Am.  Jonr.  Med.  Sciences,  August,  1897. 


DISEASES   OF   THE   OTHER   JOINTS.  369 

group  of  muscles  affected  are  as  follows:  Coraco-brachialis,  triceps,  del- 
toid, especially  the  posterior  part,  supra-  and  infra-spinatus,  rhomboids, 
levator  anguli  scapulte,  latissimus  dorsi. 

In  a  case  observed  by  one  of  the  writers  in  which  three  dislocations  of 
the  right  shoulder  had  occurred  inside  of  a  year,  each  from  a  sufficiently 
heavy  fall,  there  was  no  marked  atrophy  of  these  muscles  one  week  after 
the  third  accident. 

Limitation  of  motion  is  not  so  much  due  to  pain  or  to  fear  of  displace- 
ment, as  apparently  to  some  lesion  in  the  joint  mechanism. 

It  should  be  noted  that  a  large  proportion  of  epileptics  are  found  in 
all  reported  cases.  Reduction  is,  as  a  rule,  easy,  and  inflammatory  re- 
action in  the  joint  is  notably  slight  or  even  wholly  absent  after  reduction. 

Prognosis. — In  a  shoulder-joint  in  which  a  dislocation  has  once  or  twice 
occurred  from  insufficient  cause  it  is  not  likely  that  the  liability  will  be- 
come less  frequent  as  time  advances  if  no  treatment  is  undertaken.  As 
a  rule,  the  dislocations  will  occur  with  greater  frequency  and  from  slighter 
causes  as  time  progresses. 

Treatment. — The  methods  of  treatment  may  be  classified  under  four 
heads : 

1.  By  apparatus.  2.  By  massage  and  exercises  alone.  3.  By  tem- 
porary fixation  and  massage.     4.   By  operation. 

1.  The  use  of  apparatus  confining  the  arm  to  the  side  is  to  be  con- 
demned. It  weakens  the  muscles  by  causing  their  disuse.  It  is  uncom- 
fortable and  partially  disabling,  and  its  use  can  be  considered  justifiable 
only  temporarily  or  under  exceptional  conditions. 

An  apparatus  used  by  one  of  the  writers  seems  as  little  objectionable 
as  any.  It  consists  of  a  leather  shoulder  cap  embracing  the  arm,  strength- 
ened by  two  steel  strips,  one  horizontal  strip  running  from  before  back- 
ward and  fitting  the  outer  contour  of  the  shoulder.  The  other,  a  longi- 
tudinal strip,  runs  from  the  base  of  the  neck  to  the  middle  of  the  arm. 
There  is  a  joint  opposite  the  shoulder,  allowing  antero-posterior  motion  in 
the  shoulder.  The  shoulder  cap  is  fastened  in  place  by  a  chest  band ;  the 
apparatus  prevents  abduction  of  the  arm  to  any  degree  likely  to  produce 
dislocation. 

2.  Massage  and  exercises  without  apparatus.  This  treatment  is  based 
on  the  advisability  of  improving  the  circulation  and  nutrition  of  the 
shoulder  and  strengthening  the  atrophied  muscles.  The  shoulder  is  al- 
lowed perfect  freedom  during  this  treatment. 

3.  Fixation  in  connection  with  massage  and  exercises.  Prolonged 
fixation  is  called  for  when  a  second  dislocation  has  occurred  from  slight 
cause.  The  arm  is  lifted  by  applying  a  sling,  which  supports  the  forearm 
and  point  of  the  elbow.  The  arm  is  held  to  the  side  by  a  swathe,  thus 
preventing  all  motions  of  the  joint.  This  removes  as  much  weight  as 
possible  from  the  joint  capsule. 

24 


370  ORTHOPEDIC   SURGERY. 

Ill  connection  with  this  treatment  daily  massage  to  the  shoulder 
muscles  should  be  employed,  and  especially  to  the  muscles  found  atro- 
phied in  such  cases.  After  some  weeks  of  fixation  motion  should  be 
progressively  allowed,  along  with  massage  and  exercises  for  the  muscles 
ordinarily  affected  in  these  cases.  This  treatment  should  continue  at 
least  three  months.  Electricity  is  of  help  also  in  causing  special  con- 
tractions of  the  atrophied  muscles.  The  faradic  current  of  medium 
strength  should  be  used. 

4.    Operation. — The  operative  measures  advocated  have  been  few. 

Malgaigne  advocated  subcutaneous  incision  of  the  capsule  of  the  joint 
by  a  tenotome  introduced  anteriorly,  in  the  hope  of  producing  inflamma- 
tory contraction. 

Excision  of  the  head  of  the  humerus1  is  a  mutilating  operation,  and 
will  rarely  be  necessary.  It  is  conceivable  that  after  an  exploration  of 
the  joint  abnormalities  might  be  found  which  would  demand  an  excision. 

Gersteiy  Eicord, 3  and  Bun-ell'1  have  operated  successfully  on  five 
such  cases  by  reefing  the  anterior  part  of  the  capsule  of  the  joint  through 
an  anterior  incision. 

Obstetrical  paralysis  of  the  shoulder  will  be  considered  in  Chapter 
XV. 

Diseases  of  the  Elbow. 

Synovitis  may  appear  in  this,  as  in  other  joints,  from  the  usual  ex- 
citing causes,  and  presents  the  same  characteristics. 

Chronic  Tuberculous  Disease.  — The  disease  may  begin  with  pain,  but 
this  is  not  severe,  and  often  is  entirely  absent.  Limitation  of  extension 
of  the  forearm  is  a  constant  and  early  symptom,  motion  in  this  direction 
being  distinctly  restricted  when  flexion,  pronation,  and  supination  are 
free.  A  slight  increase  of  surface  temperature  is  usually  found,  but  its 
absence  does  not  exclude  the  disease.  Careful  examination  will  reveal  a 
slight  amount  of  swelling  even  at  this  stage  of  the  affection,  shown  by 
fulness  and  thickening  on  either  side  of  the  tendon  of  the  triceps,  and, 
looking  at  the  elbow  from  behind,  the  joint  appears  broader  than  normal. 
As  in  other  joints,  wasting  of  muscles  occurs  rapidly.  As  the  disease 
progresses  the  stiffness  increases,  motion  in  other  directions  is  restricted 
and  resisted  by  muscular  spasm,  and  the  joint  is  generally  held  at  an 
obtuse  angle.  Starting  pains  may  be  added  to  the  other  symptoms,  and 
become  the  source  of  great  discomfort.  The  whole  joint  becomes  in- 
volved in  the  swelling,  the  enlargement  assuming  a  fusiform  shape. 

JCent.   f.  Chir.,  1883,  p.  28;   Beilage  z.  Cent.   f.  Chir.,  1882,  p.  73,  and  1886,  p. 
90;  Deutsch.  Zeit.  fur  Chir.,  1880,  xiii.,  p.  167  ;  Pitha  and  Billroth,  ii.,  p.  652. 
2 "Aseptic  and  Antiseptic  Surgery,"  p.  8. 

3  Bull,  de  l'Acad.  de  MeU,  1894,  p.  334. 

4  Burrell  and  Lovett :  Am.  Jour.  Med.  Sciences,  August,  1897. 


DISEASES    OE    THE    OTHER   JOINTS. 


371 


The  swelling  sometimes  becomes  very  great.  The  skin  may  become 
riddled  with  sinuses,  the  tuberculous  infection  attacks  the  soft  parts, 
and  the  whole  elbow  becomes  a  pulpy,  granulating  mass.  This  occurs 
in  neglected  cases  of  elbow  disease,  and  also  as  the  result  of  relapses 
after  excision  of  the  joint.  Tuberculosis  of  the  head  of  the  radius  may 
exist,  in  which  case  limitation  of  rotation  and  local  swelling  are  predomi- 
nant symptoms. 

The  prognosis  in  tuberculous  disease  of  the  elbow  is  not  favorable  for 
re-establishment  of  motion,  unless  the  affection  is  treated  at  a  very  early 
stage.  The  joint  is  so  complicated  that  the  disease  involves  a  large  and 
comparatively  widespread  surface  of  synovial  membrane  before  its  pres- 


FiG.  323.— Tuberculosis  of  the  Elbow.    Advanced  stage. 


ence  is  discovered.  Other  forms  of  joint  disease  do  not  present  symp- 
toms essentially  different  from  those  noted  in  speaking  of  other  joints. 

Stiffness  of  the  elbow  is  an  affection  often  found  disassociated  with  the 
signs  of  active  disease.  It  may  result  from  fracture  with  the  formation 
of  adhesions  or  the  displacement  of  some  of  the  bony  parts  of  the  joint; 
from  synovitis  with  adhesions  of  the  joint  surfaces,  and  at  times  even 
from  very  slight  grades  of  synovitis;  and  also  it  may  result  from  chronic 
arthritis  of  a  tuberculous  or  rheumatic  type  which  has  caused  destruction 
of  the  joint  and  fibrous  or  bony  ankylosis. 

Treatment. — The  treatment  of  serious  elbow-joint  disease  is  not  at- 
tended, as  a  rule,  by  very  satisfactory  results.  Simple  synovitis  gener- 
ally recovers  under  fixation,  which  is  given  either  by  fixation  splints, 
internal  angular,  or  external  angular  splints.  These  can  be  made  of  tin 
or  pasteboard,  reinforced  with  iron  or  wire  or  wood,  and  should  be  fitted 
to  the  arm  bent  to  a  right  angle.  Compression  can  be  given  by  surround- 
ing the  joint  with  cotton  and  bandaging  it  with  an  elastic  rubber  bandage. 
In  time  fixation  by  splints  can  be  discontinued,  and  the  support  of  a 
sling  alone  relied  on,  with  passive  exercises  and  massage.  In  small  chil- 
dren, pasteboard  splints  give  enough  fixation  for  practical  purposes,  even 
in  acute  cases. 


372  ORTHOPEDIC  SURGERY. 

When  chronic  synovitis  or  suspected  ostitis  is  to  be  treated,  some- 
what more  permanent  fixation  is  demanded.  This  is  best  furnished  by 
plaster  of  Paris  or  moulded  leather,  which  can  be  worn  for  some  weeks 
aud  then  be  replaced  with  little  disturbance  of  the  joint.  The  frequent 
readjustment  of  splints  is  objectionable  in  a  sensitive  joint.  In  any  event, 
a  sling  is  to  be  carefully  worn,  which  shall  support  the  hand  and  wrist  as 
well  as  the  arm,  aud  whatever  apparatus  is  used  it  is  essential  to  remem- 
ber that  the  elbow  should  be  flexed  to  a  right  angle,  for  if  ankylosis 
occurs  in  any  other  position  a  useful  arm  is  not  obtained. 

When  the  joint  is  fixed  by  muscular  spasm  at  an  angle  greater  than  a 
right  angle,  it  will  often  be  found  possible  to  rectify  this  by  the  applica- 
tion of  a  fixation  bandage  to  the  arm  in  its  malposition.  This  so  quiets 
the  muscular  irritation  that  in  two  or  three  weeks  it  may  easily  be  bent 
\ip  a  little  and  by  the  application  of  a  succession  of  bandages  it  may  often 
be  brought  into  a  right-angled  position  without  the  use  of  the  least  force. 

If  the  disease  progresses,  it  is  of  little  use  to  continue  conservative 
treatment ;  but  one  must  proceed  to  arthrectomy,  or  better  yet,  excision, 
before  amputation  becomes  the  only  measure  holding  out  any  prospect  of 
relief.     Forcible  straightening  of  an  ankylosed  arm  is  sometimes  useful. 

Excision  of  the  elbow  is  perhaps  indicated  earlier  in  the  course  of  the 
disease  than  is  the  case  in  any  other  of  the  larger  joints.  After  in- 
fancy is  passed,  operative  interference  is  indicated  whenever  it  is  clear 
that  under  expectant  treatment  the  disease  is  growing  worse.  Under 
these  conditions,  the  results  are  not,  as  a  rule,  altogether  satisfactory, 
but  if  the  disease  is  allowed  to  go  on,  the  elbow-joint  becomes  so  disor- 
ganized that  amputation  becomes  necessary.  There  are  no  reliable  statis- 
tics dealing  with  the  results  of  the  operation,  except  those  of  Culbertson, 
relating  chiefly  to  operations  before  antiseptic  surgery  came  into  use.  Of 
290  cases  which  recovered  when  complete  excision  of  the  joint  had  been 
performed,  32  were  perfect  and  196  useful.  Oilier,  in  a  series  of  50 
cases,  had  no  death  attributable  to  operation. 

Excision  is  also  indicated  for  ankylosis  in  faulty  position,  as  when 
the  elbow  is  fixed  in  a  position  of  much  more  than  a  right  angle  or  very 
sharply  flexed.  The  longitudinal  incision  is  the  most  serviceable.  The 
forearm  is  slightly  flexed,  and  the  incision,  about  three  and  one-half 
inches  long,  is  made  a  little  to  the  inner  side  of  the  median  line  over  the 
triceps  and  ulna  and  is  carried  down  to  the  bone  throughout  its  entire 
length.  The  inner  edge  of  the  divided  periosteum  is  raised  from  the  ulna 
with  the  corresponding  half  of  the  tendon  of  the  triceps,  and  the  dissec- 
tion is  continued  with  the  knife  close  to  the  bone,  toward  the  internal 
condyle.  Much  care  must  be  taken  to  preserve  the  connection  between 
the  periosteum,  the  muscular  attachments,  and  the  internal  lateral  liga- 
ments. A  similar  dissection  should  then  be  made  upon  the  outer  side 
with  the  same  precautions.     The  humerus  is  dislocated  backward  through 


DISEASES    OF   THE    OTIIKIt   JOINTS.  373 

the  wound  and  sawed  olf  wherever  it  may  be  necessary.  In  other  cases 
it  may  be  advisable  to  use  the  keyhole  or  chain  saw,  and  so  far  as  may 
be  necessary,  the  ulna  is  cleared  and  sawed  through,  the  head  of  the 
radius  being  removed  with  the  saw  or  bone  forceps. 

In  certain  cases,  in  which  sinuses  exist,  it  may  be  better  to  adopt  some 
informal  method  of  operation  which  will  be  suggested  by  the  direction 
and  location  of  the  sinuses,  or  abscesses. 

The  after-treatment  is  similar  to  that  of  other  excisions :  complete 
rest  to  the  joint  and  fixation  in  a  right-angled  position.  This  at  first 
can  be  best  obtained  by  the  use  of  a  plaster-of -Paris  splint  applied  out- 
side of  a  large  antiseptic  dressing.  Later,  in  the  course  of  the  convales- 
cence, bracketed  tin  or  wooden  splints  may  be  of  use;  or,  if  one  desires, 
the  original  plaster-of -Paris  splint  may  be  bracketed  with  strips  of  iron. 

In  excision  for  elbow  disease,  as  a  rule,  ankylosis  is  aimed  at  as  the 
best  possible  result,  so  that  passive  motion  is  not  to  be  considered ;  if, 
however,  the  operation  is  performed  in  adults  for  ankylosis  or  injury  and 
the  ligaments  have  been  in  a  measure  fairly  preserved  during  the  opera- 
tion, it  may  be  advisable  to  begin  passive  motion  after  a  moderate  degree 
of  firmness  in  the  tissues  has  been  reached,  as  there  is  but  little  danger 
of  a  flail  joint,  and  it  is  reasonable  to  expect  that  a  certain  degree  of 
motion  at  the  joint  may  thus  be  obtained. 

Arthrectomy :  — In  place  of  a  formal  excision,  the  elbow  can  be  incised, 
and  all  attainable  tuberculous  tissue  dissected  out  and  the  bone  curetted. 
This  is  a  procedure  especially  useful  in  children,  but  the  complicated 
nature  of  the  articulation  makes  it  difficult  to  remove  at  all  thoroughly 
the  diseased  synovial  membrane.  The  operation  of  arthrectomy  was  con- 
sidered in  detail  in  speaking  of  tumor  albus. 

Diseases  of   the  Wrist. 

Synovitis  may  occur  under  the  same  conditions  existing  in  other 
joints.  Tenosynovitis  is  characterized  by  pain  on  the  motion  of  certain 
fingers,  with,  perhaps,  a  sensation  of  rubbing  or  creaking  in  the  affected 
tendons.  Tender  points  are  present  in  the  course  of  these  tendons.  In 
the  superficial  tendons  of  the  wrist,  some  distention  of  the  synovial  ten- 
dinous sheath  can  be  seen. 

Chronic  Arthritis  Deformans. — The  wrist  is  a  common  seat  of  this 
affection,  with  the  ordinary  symptoms  of  pain,  swelling,  stiffness,  creak- 
ing, etc.  When  deformity  has  occurred,  the  wrist  is  generally  flexed, 
and  the  distal  ends  of  the  radius  and  ulna  are  enlarged  and  project  back- 
ward. Frequently  the  hand  is  adducted,  this  often  being  associated  with 
a  similar  distortion  of  the  fingers. 

Arthritis  deformans  and  other  forms  of  synovitis  of  the  wrist  should 
be  treated  on  the  principles  already  indicated  for  these  affections. 


371  ORTHOPEDIC   SURGERY. 

Tuberculous  disease  is  characterized  by  swelling,  heat,  and  stiffness. 
If  the  disease  is  advanced,  deformity  and  swelling  will  be  added  to  the 
other  signs.  The  hand  may  be  held  flexed  on  the  forearm  at  an  angle 
of  120  to  130°,  and  this  position  is  fairly  constant.  Swelling  ap- 
pears first  in  the  depressions  between  the  tendons.  Later,  measurement 
will  sIioav  the  •  joint  to  have  increased  in  circumference,  and  there  is  a 
fulness  of  outline,  especially  on  the  dorsal  surface,  and  in  destructive  dis- 
ease the  swelling  extends  up  on  the  forearm  and  down  on  the  hand.  Sup- 
puration is  very  liable  to  occur,  and  the  course  of  the  disease  is  usually 
long  and  slow. 

In  the  matter  of  diagnosis,  it  may  be  added  that  swelling  is  always 
present,  and  that  with  the  wasting  of  the  muscles,  the  heat,  and  the  lim- 
itation of  motion,  it  makes  up  the  clinical  picture  of  the  disease. 

In  tuberculous  disease  of  the  wrist-joint,  fixation  is  indicated,  and  it 
is  most  easily  obtained  by  the  application  of  anterior  and  posterior  com- 
mon wooden  splints  and  carrying  the  arm  in  a  sling.  Plaster  of  Paris 
forms  a  more  permanent  dressing,  and  is  equally  comfortable. 

Treatment. — The  conservative  treatment  of  disease  of  the  wrist  must 
not  be  dismissed  without  a  mention  of  the  great  benefit  often  to  be  de- 
rived from  compression  and  fixation  together.  This  is  obtained  in  the 
Gamgee  dressing.  Not  only  in  ostitis,  but  in  teno-synovitis  and  simple 
sprained  wrist,  this  method  is  of  very  great  value.  As  a  rule,  the  active 
symptoms  subside  when  rest  is  furnished  to  the  diseased  joint;  but  the 
cure  of  the  disease  is  another  matter  and  requires  a  long  time.  The 
great  extent  and  free  communication  of  the  synovial  sacs  of  the  wrist 
make  the  disease  an  extensive  one  when  located  there. 

Excision  of  the  joint  is  indicated  in  the  severest  cases,  or  in  those 
which  progress  badly  under  conservative  treatment.  In  a  series  of  79 
cases  of  excision  of  the  wrist,  the  results  in  24  per  cent  were  worthless, 
4C>  per  cent  secured  useful  limbs,  and  in  8  per  cent  perfect  results  fol- 
lowed the  operation.  In  this  series  of  cases  both -partial  and  complete 
excisions  are  included.  Gross  gives  in  his  tables  a  mortality  of  about 
11.7  per  cent  for  excisions  and  12.8  per  cent  for  amputations  of  the 
forearm.  Oilier  reports  seventeen  resections  of  the  wrist-joint  in  which 
the  results  were  excellent ;  subsequent  amputation  was  needed  in  none, 
and  all  recovered  with  useful  hands,  being  able  either  to  write  or  to  carry 
out  light  work,  and,  in  some  cases,  to  lift  weights.  Motion  at  the  finger- 
joints  and  at  the  wrist  became  quite  free.  The  best  result  is  either  anky- 
losis or  limited  motion,  and,  therefore,  as  much  bone  as  possible  should 
be  saved.  Other  things  being  equal,  a  loose  joint  entails  less  power  in 
the  hands  and  fingers. 

According  to  Culbertson's  tables,'  however,  the  results  in  resection  at 

1  Transactions  American  Medical  Association,  1876,  supplement  to  vol.  xxvii.  ; 
Boston  Medical  and  Surgical  Journal,  October  26th,  1882,  p.  388. 


DISEASES   OF   THE   OTHER   JOINTS.  375 

the  wrist-joint  would  appear  to  be  rather  more  favorable  than  indicated 
by  Bidder.1  In  the  table  of  excisions  of  the  wrist  for  disease,  7.59  per 
cent  secured  "perfect"  results,  45.57  per  cent  "useful"  limbs,  24.0.'5  per 
cent  "worthless"  limbs.  The  average  period  of  recovery  in  thirty-five 
cases  was  nearly  two  and  a  half  years. 

The  method  of  Lister  is  performed  by  a  radial  and  dorsal  incision. 
The  radial  incision  commences  at  the  middle  of  the  dorsal  aspect  of  the 
radius  at  the  level  of  the  styloid  processes.  It  is  directed  toward  the 
inner  side  of  the  metacarpo-phalangeal  articulation  of  the  thumb,  and  on 
reaching  the  radial  border  of  the  second  metacarpal  bone  it  is  carried 
downward  longitudinally  for  half  the  length  of  the  bone.  The  soft  parts 
are  detached  from  the  bones  with  the  periosteal  elevator  or  the  blade  of 
the  knife,  and  the  radial  artery  is  thrust  somewhat  outward.  The  soft 
parts  on  the  ulnar  side  are  dissected  up  as  far  as  is  practicable,  while 
the  extensor  tendons  are  relaxed  by  bending  back  the  hand.  The  knife 
is  then  entered  on  the  inner  side  of  the  arm  for  the  ulnar  incision  two 
inches  above  the  end  of  the  ulna,  and  is  carried  downward  in  a  straight 
line  as  far  as  the  middle  of  the  fifth  metacarpal  bone  at  its  palmar  aspect. 
The  tendon  of  the  extensor  carpi  ulnaris  is  cut  at  its  insertion  into  the 
fifth  metacarpal  and  dissected  up  from  its  groove  in  the  ulna,  while  the 
tendons  of  the  extensors  of  the  fingers  with  the  radius  are  left  undis- 
turbed. The  anterior  surface  of  the  ulna  is  cleared  by  cutting  close  to 
the  bone.  The  anterior  ligament  of  the  wrist-joint  is  divided  and  the 
junction  between  the  carpus  and  the  metacarpus  is  cut,  the  former  being 
extracted  through  the  ulnar  incision  by  bone  forceps  and  the  use  of  the 
knife. 

If  the  hand  is  deverted,  the  articular  heads  of  the  radius  and  ulna  will 
protrude  at  the  ulnar  incision,  and  as  much  as  may  be  necessary  is  then 
removed.  The  metacarpal  bones  are  also  protruded  and  dealt  with  in  the 
same  way.  The  articular  surface  of  the  pisiform  bone  is  cut  off  and  the 
trapezium  is  dissected  out.  The  operation  may,  however,  be  performed 
by  a  long,  single  dorsal  incision,  a  method  identified  with  the  name  of 
Langenbeck,  which  should  begin  at  the  centre  of  the  ulnar  border  of  the 
metacarpal  bone  and  the  index  finger,  and  be  carried  upward  to  the  mid- 
dle of  the  dorsal  surface  of  the  epiphysis  of  the  radius,  and  dissected 
down  to  the  bone.  The  sheaths  of  the  tendons  are  lifted  with  the  peri- 
osteum and  carried  to  the  radial  side  of  the  long  incision;  the  hand  is 
flexed  and  the  articular  surface  of  the  upper  row  of  carpal  bones  is  ex- 
posed. The  ends  of  the  radius  and  ulna  may  be  denuded  and  thrust 
through  the  wound  and  sawed  off  in  the  usual  way.  Here,  as  in  other 
excisions,  informal  methods  of  operating  may  be  necessary  on  account  of 
the  situation  of  abscesses  and  sinuses. 

1  Archiv  f.  klin.  Chir.,  1883,  28  Bd.,  iv. ,  p.  822. 


376  ORTHOPEDIC   SURGERY. 

The  operation  is  indicated  when  expectant  treatment  has  failed,  but 
the  joint  is  so  easily  fixed  and  so  accessible  that  mechanical  treatment 
works  at  good  advantage.  Operation  is  attended  with  so  much  deform- 
ity of  the  wrist  and  such  doubtful  results  on  account  of  the  very  exten- 
sive surface  of  the  serous  membrane  that  excision  should  not  be  lightly 
undertaken.  The  after-treatment  is  simple,  because  the  hand  can  be 
kept  so  easily  at  rest  upon  a  palmar  splint;  but  any  form  of  splint  may 
be  applied  which  will  afford  permanent  and  efficient  fixation.  In  chil- 
dren excision  should  be  done  only  in  severe  cases,  when  conservative 
treatment  has  failed.  As  in  ankle-joint  excision  the  whole  of  every 
diseased  carpal  bone  should  be  removed. 

Sacro-Iliac  Disease. 

This  affection  is  also  known  as  sacro-coxitis  (Hueter),  sacrarthrocace, 
and  sacro-coxalgie.  By  sacro-iliac  disease  is  meant  disease  of  the  sacro- 
iliac synchondrosis. 

Disease  of  this  joint  is  a  rare  condition.  It  is  essentially  a  disease  of 
young  adult  life,  being  slightly  more  common  in  men  than  in  women. 
Delens  cites  20  cases  in  which  the  age  ranged  from  18  to  45  years,  and 
the  youngest  case  which  came  under  Erichsen's  observation  was  a  patient 
14  years  old.  Van  Hook,  in  32  cases  in  which  the  age  was  recorded,  found 
that  less  than  22  per  cent  were  below  15  years  of  age.1  Poore,  however, 
reports  cases  which  he  has  seen  in  young  children.  The  acute  form  of 
the  disease,  which  is  extremely  rare  and  quite  violent,  runs  its  course 
rapidly,  attended  by  high  fever  and  suppuration,  and  is  apt  to  terminate 
fatally  from  exhaustion.  The  chronic  form  practically  means  tubercu- 
lous disease,  although  some  writers  would  classify  these  cases  under  three 
heads :  tuberculous,  puerperal  (pysemic),  and  gonorrhceal,  with  a  fourth 
class  possible,  i.e.,  syphilitic." 

Pathology. — The  pathological  lesions  which  are  found  in  these  cases 
are  not  unlike  those  accompanying  chronic  inflammation  in  other  joints. 

Etiology. — The  etiology  is  also,  in  large  part,  similar  to  that  of 
chronic  disease  of  this  type  in  other  joints;  traumatism  and  the  strain  of 
parturition  being  assigned  as  the  commonest  causes.  Chauvel 2  asserts 
that  the  affection  is  fairly  common  in  young  cavalry  soldiers,  and  assigns 
as  the  exciting  cause  the  traumatism  from  the  equestrian  exercise,  this 
joint  being  called  upon  to  support  the  weight  of  the  trunk. 

Symptoms. — In  the  early  part  of  the  disease,  such  symptoms  as  a 
slight  abdominal  distress,  difficulty  in  micturition  or  in  evacuation  of  the 
bowels,  easy  fatigue,  a  feeling  of  indisposition,  etc.,  are  often  present, 
and  as  the  disease  progresses  more  pronounced  signs  appear.     Pain  is 

1  Van  Hook  :  Ann.  of  Surgery,  1888-89. 

2  "  Ref.  Handbook  of  the  Med.  Sciences,"  vol.  vi.,  p.  240. 


DISEASES   OF   TUK   OTHER   JOINTS. 


377 


nearly  always  present,  and  may  vary  much  in  intensity.  It  is  made 
worse  by  standing,  and  is  almost  always  relieved  by  lying  down.  It  is 
also  apt  to  be  more  severe  at  night,  and  is  increased  by  pressure  upon  the 
trochanters  or  wings  of  the  ilia.  The  pain  varies  in  situation,  and  may 
be  referred  to  the  course  of  the  sciatic  nerve.  Sensitiveness  upon  press- 
ure over  the  joint  is  a  common  symptom,  and  this  may  be  developed 
over  the  anterior  part  of  the  joint  by  palpation  through  the  rectum. 
Some  swelling,  or  a  boggy  feeling,  is  usually  present  about  the  articula- 
tion, and  if  it  goes  on  to  abscess  formation  the  fluctuating  swelling  may 
present  at  almost  any  point,  either  directly  backward  into  the  lumbar 
region,  or  it  may  become  intrapelvic,  in  which  case  it  may  appear  in  the 
groin  as  a  psoas  abscess,  or  point  in  the  ischio- 
rectal fossa,  or  at  either  of  the  sacro-sciatic 
notches.     Limping  is  practically  always  present. 

The  position  of  the  body  in  walking  or  stand- 
ing is  fairly  characteristic,  the  weight  of  the  trunk 
being  thrown  upon  the  well  foot,  while  the  other 
leg  hangs  down ;  this  exerts  a  slight  extension  by 
its  weight.  In  walking  the  gait  is  very  cautious, 
all  jar  is  avoided,  and  hence  the  toe  is  largely 
used  instead  of  the  flat  of  the  foot  on  the  diseased 
side.  Atrophy  of  the  muscles  of  the  leg  upon  the 
affected  side  is  usually  present,  and  is  seen,  as  in 
other  chronic  joint  affections,  quite  early  in  the 
disease.  * 

Diagnosis. — Sacro-iliac  disease  has  been  mis- 
taken for  sciatica,  but  aside  from  the  fact  that 
the  latter  is  usually  found  later  in  life,  the  pains 
are  not  relieved  by  the  recumbent  position. 

In  lumbago  the  pain  is  more  diffuse  and  higher 
up  than  in  disease  of  the  sacro-iliac  articulation. 

Inflammation    of   the   psoas    muscle    (psoitis) 
more  usually  simulates  hip  disease,  but  it  may  be  mistaken  for  sacro- 
iliac disease.      In  this  there  is  no  tenderness  over  the   joint,   and  the 
pain  which  is  present  is  increased  by  extension  of  the  thigh,  while  flexion 
relieves  it. 

Positive  diagnosis  of  sacro-iliac  disease  from  hip  disease  and  Pott's 
disease  in  the  lumbo-sacral  region  is  at  times  difficult  and  often  impos- 
sible, especially  in  the  class  of  cases  just  referred  to.  In  hip  disease  all 
manipulation  is  resisted  by  muscular  spasm,  while  in  sacro-iliac  disease, 
with  the  iliac  bones  held  firmly,  all  motions  at  the  hip  are  possible  with- 
out pain.  Also  in  hip  disease  the  pain  is  never  increased  by  pressure 
upon  the  wings  of  the  ilia  as  is  the  case  in  sacro-iliac  inflammation.  In 
spinal  caries  we  have  a  prominence  of  some  of  the  spinous  processes  with 


Fig.  324.— Attitude  in  Sacro- 
iliac Disease. 


378  ORTHOPEDIC   SURGERY. 

rigidity  of  the  spine  when  motion  is  attempted,  and  local  tenderness  is 
not  present  over  the  sacro-iliac  articulation,  nor  does  pressing  together 
the  ilia  cause  pain. 

Prognosis. — The  prognosis  in  this  disease  is  at  best  quite  grave. 
Cases  do  xecover,  but  it  is  one  of  the  most  chronic  of  joint  affections,  and 
usually  goes  oh  to  abscess  formation,  with  prolonged  suppuration  and 
death  either  from  exhaustion,  renal  complications,  or  secondary  tubercu- 
losis. 

Van  Hook  '  reported  thirty-eight  cases  with  abscess,  of  which  only 
three  recovered. 

Treatment. — The  principles  of  treatment  are  the  same  as  in  all  chronic 
joint  affections.  In  the  acute  stage  the  patient  should  be  kept  upon  the 
back  in  bed,  with  weight-and-pulley  extension  to  the  leg,  and  as  the 
acute  symptoms  abate  he  may  be  allowed  to  go  about  on  crutches,  with 
a  high  sole  upon  the  well  foot,  the  weight  of  the  other  leg  serving  as  ex- 
tension. "While  moving  about,  a  certain  amount  of  comfort  may  be  de- 
rived from  a  swathe,  either  of  cotton  or  of  adhesive  plaster,  about  the 
pelvis,  which  serves  in  part  to  fix  the  joint. 

Wrhen  an  abscess  has  formed,  it  should  at  once  be  laid  open,  any 
diseased  bone  removed,  and  treated  like  any  cold  abscess.  When  the 
abscess  is  intrapelvic  it  may  be  quite  difficult  to  reach,  and  Van  Hook 
describes  a  very  ingenious  method  for  reaching  and  draining  the  cavity. 
An  incision  is  made  near  the  posterior  part  of  the  crest  of  the  ilium  on 
the  affected  side,  the  tissues  are  divided  down  to  the  bone,  and  a  piece 
of  the  ilium  is  chiselled  away.  This  brings  tfte  joint  within  reach,  and 
through  the  opening  any  diseased  bone  may  be  removed  and  the  cavity 
drained.  Excision  of  the  sacro-iliac  synchondrosis  may  be  done  in  severe 
cases.      Such  cases  have  been  reported  by  Buchanan." 

In  all  of  these  cases  tonics  and  constitutional  treatment  are  not  to  be 
neglected. 

Phalangeal  Articulations. — Owing  to  their  position  exposed  to  sprains, 
blows,  etc.,  the  phalangeal  joints  are  frequently  found  enlarged,  slightly 
deformed,  and  stiff. 

The  hand  is  a  very  common  seat  of  arthritis  deformans,  which  often 
begins  in  one  or  two  joints  of  one  finger,  and  some  time  elapses  before  it 
attacks  the  others.  The  joints  become  much  enlarged,  and  distortion 
usually  occurs  to  the  ulnar  side,  this  adduction  being  chiefly  in  the 
metacarpo-phalangeal  joint.  The  fingers  may  become  permanently  dis- 
torted, flexed  or  abducted,  or  both ;  the  second  phalanges  of  the  fingers, 
as  well  as  of  the  thumb,  are  usually  extended,  giving  a  characteristic  ap- 
pearance to  the  hand. 

1  Journal  of  the  American  Medical  Association. 
-  Memphis  Lancet,  December.  1808. 


DISEASES   OF   THE   OTHER   JOINTS.  379 

Temporo- Maxillary  Articulation. — By  far  the  most  common  affection 
of  this  joint  occurs  in  chronic  rheumatoid  arthritis,  which  presents  the 
same  characteristics  as  when  occurring  elsewhere  and  which  may  result 
in  ankylosis. 

Tuberculous  disease  may  occur,  secondary  to  disease  of  the  ramus  or 
ear,  but  it  is  rare. 

Subluxations  occur  from  relaxation  of  the  ligaments,  usually  in 
young  people,  and  most  frequently  women.  The  patient  suddenly  finds 
himself  unable  to  close  the  mouth,  and  until  he  has  acquired  the  method 
of  reducing  the  dislocation  himself,  it  must  be  accomplished  in  the  rou- 
tine way  as  in  the  treatment  of  traumatic  dislocation.  A  tendency  to 
this  accident,  once  established,  is  usually  permanent. 

A  blister  applied  over  the  articulation  sometimes  appears  to  have  a 
beneficial  effect,  but  generally  the  affection  becomes  better  or  worse  in- 
dependent of  any  treatment,  local  or  general,  at  times  causing  a  great 
amount  of  discomfort  and  at  other  times  not  being  noticeable. 

Stemo- Clavicular  and  Acromio- Clavicular  Joints.  —  Enlargement  of 
these  joints  sometimes  occurs  in  persons  accustomed  to  hard  work  with 
their  upper  extremities.  Inflammation  of  the  sterno-clavicular  articula- 
tion, followed  by  suppuration,  is  occasionally  observed,  but  presents  no 
unusual  symptoms.  Chronic  rheumatoid  arthritis  may  occur  in  either  of 
these  joints,  causing  pain  and  stiffness,  enlargement,  and  weakness  of 
the  upper  extremity. 

Articulation  of  the  First  and  Second  Pieces  of  the  Sternum. — Disease 
in  this  situation  is  rare,  but  has  been  described  by  Hilton.  The  symp- 
toms were  pain  about  the  sternum,  especially  severe  on  forced  or  sudden 
respiratory  exertion,  and  great  tenderness  over  the  joint.  Eecovery  took 
place.     Fixation  and  expectancy  are  all  that  can  be  done  for  these  joints. 

Symphysis  Pubis. — Cases  are  recorded  of  chronic  disease  of  this  joint,1 
as  Avell  as  of  its  complete  ossification  in  comparatively  young  people.'2 

Sacro- Coccygeal  Disease. — Disease  of  the  coccygeal  joint  is  rare,  yet 
several  well-marked  cases  have  been  recorded.  The  condition  may  be 
detected  by  means  of  the  thickening  over  the  joint  and  pain  upon  motion. 
By  the  rectum,  distinct  grating  of  the  diseased  surfaces  may  be  felt  when 
the  joint  is  moved.  When  the  joint  is  clearly  involved,  excision  of  the 
coccyx  is  the  best  treatment.     Ankylosis  is  not  a  rare  occurrence,  and 

the  union  may  take  place  with  the  bones  in  almost  any  position. 

. # 

1  Holmes1  "System  of  Surgery,"  vol.  iv.,  p.  88;  Bryant:  "Practice  of  Surgery," 
p.  919. 

-  Otto,  quoted  by  Holmes. 


CHAPTER  XL 

CLUB-FOOT. 

Frequency. — Anatomy. —  Causation. —  Symptoms.—  Diagnosis. —  Prognosis. — Treat- 
ment. — C  lub-hand. 

The  term  club-foot  is  popularly  applied  to  a  deformity  characterized 
by  an  inversion,  torsion,  and  depression  of  the  front  part  of  the  foot  with 
an  elevation  of  the  heel. 

In  walking  on  a  foot  thus  deformed,  the  weight  of  the  body  is  borne, 
not  by  the  sole  of  the  foot,  but  by  the  outer  side,  and  in  extreme  cases 
by  the  dorsum  of  the  foot. 

The  distortion  is  also  known  as  talipes  equino-varus. 

Other  names  in  use  are :  "  Eeel "  foot — Pes  contortus. 

German:  Klump-Fuss. 

French :  Pied  bot. 

The  deformity  is  either  congenital  or  acquired. 

Frequency. — Club-foot  is  by  no  means  an  uncommon  distortion,  and 
was  mentioned  in  literature  even  in  the  days  of  Homer. '  Tamplin,  among 
10,217  cases  of  deformity  treated  at  the  Eoyal  Orthopedic  Hospital, 
met  with  6, 754  club-feet,  of  which  1, 780  were  congenital.  Chaussieur, 
among  22,923  newly  born  infants,  reports  37  cases  of  club-foot.  Lanne- 
longue,  among  15,229  births  at  the  Paris  Maternity  Hospital,  found  8; 
and  Duval,  in  1,000  cases  of  club-feet,  found  574  congenital,  of  which 
364  were  males  and  210  were  females. 

Anatomy. 

The  deformity  is  a  dislocation  inward  of  the  anterior  part  of  the  foot, 
the  dislocation  taking  place  at  the  medio-tarsal  articulation.  All  the 
tissues  are  necessarily  affected  by  the  abnormal  position,  and  the  skin, 
muscles,  tendons,  and  fascia?  are  all  altered. 

In  all  cases  of  cougenital  club-foot,  even  in  that  of  a  full-term  foetus, 
the  scaphoid  bone  will  be  found  articulating  with  the  side  of  the  head  of 
the  astragalus  rather  than  with  the  anterior  surface.  The  articulation  is 
also  more  toward  the  under  side  of  the  astragalus,  the  head  of  which  is 
thus  uncovered. 

1  "Iliad,"  i.,  599;  xxi.,  331. 


CLUB-FOOT. 


181 


The  scaphoid  may  he  so  far  distorted  to  the  side  as  to  articulate  at 
one  end  with  the  tip  of  the  internal  malleolus.  In  one  instance  in  the 
ankle  of  a  full-term  foetus,  dissected  by  the  writers,  a  separate  synovial 
sac  was  found  between  the  end  of  the  astragalus  and  the  malleolus. 
In  infantile  cases  the  distortions  in  the  shape  of  the  bones  are  of  little 
importance,  as  the  ends  of  the  bones  are  largely  cartilaginous.  The  posi- 
tion of  the  tarsal  bones  is,  however,  not  the  normal  one.  The  cuneiform 
bones  being  intimately  connected  with  the  scaphoid  follow  the  displace- 
ment of  the  latter,  and  the 
same  is  true  of  the  metatarsal 
bones  and  the  phalanges,  so 
that  the  long  axis  of  the  front 
of  the  foot  forms  a  right  angle, 
or  even  an  acute  angle,  with 
the  axis  of  the  leg.  The  cu- 
boid is  necessarily  displaced  to 
the  inner  side  and  does  not  ar- 
ticulate with  the  front  of  the 
os  calcis,  the  facet  of  which 
also  inclines  obliquely  to  the 
inner  side. 

In  fully  developed  cases, 
and  in  older  children  or  adults, 
there  is  a  marked  alteration  in 
the  shape  of  the  bones.  The 
alterations  of  the  bones  which 
have  been  noticed  are  chiefly 
in  the  position  and  shape  of 
the  following  bones:  viz.,  the 
os  calcis,  cuboid,  astragalus, 
and  scaphoid. 

The  os  calcis,  by  the  ele- 
vation of  the  tuberosity,  is  drawn  from  a  horizontal  into  a  position  ap- 
proaching the  vertical.  It  is  also  more  or  less  rotated  on  its  vertical 
axis,  so  that  its  anterior  extremity  is  directed  outward  and  the  posterior 
extremity  inward,  and  thus  the  anterior  articulating  facet  is  oblique  to 
the  axis  of  the  bone.  The  cuboid  bone  maintains  its  connection  with 
the  os  calcis,  but  follows  the  inward  direction  of  the  anterior  extremity 
of  the  foot. 

There  is  no  rotation  of  the  astragalus  on  the  vertical  axis,  but,  as 
has  been  stated,  it  is  depressed  forward  on  its  horizontal  axis,  so  that 
only  the  posterior  portion  of  its  superior  articular  surface  is  in  contact 
with  the  inferior  articular  surface  of  the  tibia,  and  the  anterior  part  of 
its  anterior  facet  projects  beneath  the  skin  of  the  dorsum  of  the  foot. 


Fig.  325.— Dissection  of  Normal  Foot.    (Bun-ell.) 


$82 


ORTHOPEDIC    SURGERY. 


Besides  this  displacement,  the  shape  of  the  bone  is  altered  by  the  twist- 
ing inward  of  the  head  and  neck,  so  that  the  anterior  articular  sur- 
face looks  inward  instead  of  forward,  and  the  disposition  of  the  cartilage 
at  the  articulating  surfaces  of  the  head  of  the  astragalus  is  necessarily 
altered.  The  three  cuneiform  and  the  three  metatarsal  bones  being 
closely  connected  with  the  scaphoid  are  more  twisted  to  the  inside  than  is 
the  case  with  the  cuboid,  though  the  metatarsals  are  not  all  equally  in- 
volved in  the  rotation  from  without  inward  and  are  spread  out  something 

as  the  branches  of  a  fan,  in 
such  a  way  that  the  anterior 
part  of  the  foot  is  enlarged 
more  than  normal.  Besides 
these  alterations  in  the  position 
of  the  foot  others  take  place 
secondarily,  depending  on  pres- 
sure and  the  effect  of  locomo- 
tion on  the  distorted  bones. 

The  different  tendons  as- 
sume an  abnormal  direction 
and  in  general  are  carried  far- 
ther to  the  inside  than  is  nor- 
mal ;  this  is  especially  true  of 
the  tibialis  anticus,  the  com- 
mon extensor  of  the  toes,  and 
the  long  extensor  of  the  great 
toe.  Synovial  bursse  may  form 
on  the  outer  edge  and  back  of 
the  foot,  which  may  become 
inflamed  and  suppurate ;  corns 
and  callosities  are  also  formed 
on  the  skin,  from  the  pressure 
of  walking.  No  change  has 
been  found  in  the  nerves  or  the  spinal  cord  in  cases  of  club-foot. 

In  extreme  cases  there  may  be  slight  alteration  in  the  shape  of  the  femur, 
and  a  laxity  at  the  knee-joint;  the  tibia  has  also  been  found  altered,  and 
the  same  is  true  of  the  fasciae.  The  muscles  are  never  found  paralyzed  in 
congenital  club-foot,  but  the  contracted  muscles  seem  more  developed  than 
the  lengthened  muscles.  The  muscles  of  the  leg  atrophy  from  disuse, 
and  the  leg  is  much  smaller  and  the  foot  shorter  than  normal. 

In  addition  to  the  faulty  shape  of  the  bones  there  is  a  change  in  the 
ligaments  and  fasciae,  and  this  is  not  confined  to  the  severe  and  most  in- 
veterate cases,  but  is  always  present.  Not  only  are  the  plantar  ligaments 
and  fascige  contracted,  but  the  internal  lateral  and  posterior  ligaments 
are  also  contracted. 


Fig.  326.— Dissection  of  Club-foot.    (Burrell.) 


CLUB-FOOT. 


383 


Causation. 


The  deformity  is  usually  a  congenital  one,  but  it  may  also  be  acquired, 
after  the  impairment  of  muscular  power  which  takes  place  in  paralysis, 


Fig.  327.— Section  of  Foot  and 
Leg  In  Club-foot. 


FIG. 


328.— Section  of  Foot  and 
Leg.    Normal. 


Fig.  329.— Relation  of  Astraga- 
lus to  Os  Calcis.     (Whitman J 


and  after  accident.     In  regard  to  the  etiology  of  congenital  club-foot, 
various  theories  have  been  advanced  in  explanation  of  the  deformity. 

A  popular  idea  is  that  the  distortion  is  due  to  maternal  impressions, 
but  no  conclusive  evidence  in  regard  to  this  has  been  obtained.     Dabney' 


■^ 


Fig.  330.— Relation  of  Astragalus  to  Os  Cal- 
cis in  Flat-foot.    (Whitman.) 


Fig.  331.— Normal  Adult  Astragalus. 


collected  ninety  cases  of  maternal  impressions   apparently  causing  de- 
formity.    In  none  of  these  was  club-foot  produced. 

Heredity,  on  the  part  of  both  the  father  and  mother,  has  been  estab- 
lished without  doubt  in  a  certain  number  of  cases,  but  in  a  very  large 
majority  no  trace  of  similar  deformity  in  ancestors  can  be  found.     Devay 


Dabney  :  "Cyclopedia  of  Diseases  of  Children,"  vol.  i. 


384 


ORTHOPEDIC   SURGERY. 


aud  Boudin  report  that  more  cases  of  club-foot  are  found  in  children 
from  marriages  of  kin  than  among  others.  One  case  in  164  births  from 
marriages  of  kin,  and  1  case  in  1,903  of  other  marriages  are  reported. 


Fig.  332.— Astragalus  from  an  Adult 
Club-foot. 


Fig.  333.— The  Os  Calcis  in.  a,  child 
of  one  year  with  club-foot ;  h,  normal 
new-born  ;  c,  new-born  infant  with 
club-foot. 


Fig.  334.— obliquity  of 
Neck  of  Astragalus. 


The  chief  theories  which  are  advocated  to  explain  the  deformity  in 
uterine  life  are  as  follows : 

First. — Abnormal  compression  in  the  uterine  cavity. 

Second. — Retraction  or  paralysis  of  muscles  depending  or  not  on  lesion 
of  the  nervous  system  occurring  in  utero. 

Third. — A  malformation  depending  upon  arrest  of  development  of  the 
foot. 

The  first  of  these  explanations  is  as  old  as  Hippocrates.  Ambrose 
Pare  and  Cruveilhier  maintained  the  same  idea,  except  that  the  latter 


Fig.  335.  —  Side 
View  of  Astragalus 
Normal  and  in  Club- 
foot. 


Fig.  336.— From  Specimen  of  Adult  Club-foot. 


Fig.  337.— Compression 
of  Foetus  in  Utero.  (Par- 
ker.) 


believed  that  a  blow  received  by  the  mother  was  an  influential  cause,  and 
states  that  when  club-foot  is  single,  the  anterior  foot  in  utero  is  the  one 
affected,   and  when  the  deformity  is  double,  the    anterior  foot  in  the 


CLUB-FOOT. 


•uterus  is  affected  to  a  greater  degree.      Malgaigne  also  maintained   the 
same  opinion. 

The  theory  of  abnormal  difference  in  the  strength  of  the  leg  muscles 
dependent  or  not  on  disturbances  of  the  central  nervous  system  has  been 

+ 


FIG.   338. 


M,  Malleolus;       cU    astragalo  -  scaphoid        Fm.  339.- Pes  Varus  in  an  Adult.     (Schrei- 
articulation.    (Schreiber.)  ber.) 


held  by  many  writers.  Morgagni,  Benjamin  Bell,  and  Delpech  believed 
that  the  contraction  of  certain  muscles  caused  the  deformity,  while 
Beclard  believed  the  weakness  of  other  muscles  was  the  influential  factor. 
Confirmatory  of  this  view  is  the  fact  that  the  deformity  is  often  seen  in 
hydrocephalic  and  anencephalic  foetuses,  and  those  suffering  from  spina 
bifida.  But  this  idea  is  not  supported  by  the  fact  that  in  a  large  major- 
ity of  cases  no  alteration  of  the  nervous  system  can  be  found.     Out  of 


Fig.  340. — Congenital  Talipes  Equ1- 
no-vams. 


Fig.  341.— Adult  Club-foot  with  Outer  Edge  of  the  Foot  Resting 
on  the  Ground  in  Walking. 


688  cases  of  congenital  varus  in  the  London  hospitals,  only  2  were  af- 
fected with  spina  bifida.     Duval,  out  of  574  cases  of  club-foot,  found  no 
other  deformity  present ;  Lannelongue  found  in  78  cases  of  monstrosities 
25 


386 


ORTHOPEDIC   SURGERY 


27  which  were  free  from  club-foot,  and  in  32  cases  of  spina  bifida  and 
encephalocele  only  4  club-feet  were  seen. 

The  third  theory,  that  of  arrest  of  development  of  the  foot,  is  the  one 
maintained  by  Meckel,  Saint  Hilaire,  Adams,  Hueter,  and  others.  Ac- 
cording to  these  authors,  since  the  feet 
are  developed  normally  at  the  sixth  or 
seventh  week,  the  foetus  has  the  sole 
turned  inward,  and  a  permanence  of  this 
position  would  give  rise  to  a  club-foot. 

Cruveilhier  has  denied  this  anato- 
mical fact,  but  it  is  maintained  by  Martin 
and  others;  and  although  this  theory 
explains  the  deformity  of  varus,  it  is 
incapable  of  explaining  that  of  other 
varieties  of  congenital  talipes.  This 
theory  has  been  modified  so  as  to  admit, 
not  only  the  arrest  of  development  prop- 
erly so  called,  but  the  malformation 
of  the  bone  which  forms  the  skeleton; 
an  opinion  defended  by  Bouvier,  Brocher,  Lannelongue,  and  others. 

The  subject  of  the  causation  of  club-foot  has  been  carefully  investi- 
gated by  Parker  and  Shattuck, '  Berg,2  and  Scudder,3  but  the  subject  is 
still  unsettled,  though  their  investigations  seem  to  point  to  retarded  rota- 
tion as  the  immediate  cause  of  the  deformity. 

Parker  and  Shattuck  have  called  attention  to  the  fact  that  in  anthro- 
poid apes  there  is  an  inward  obliquity  of  the  neck  of  the  astragalus,  and 


Fig.342.— Congenital  Equino-varus,  Show 
ing  Position  of  Head  of  Astragalus. 


Fig.  343.— Infantile  Equino-varus. 


Fig.  344.— Severest  Form  of  Club-foot 


yet  no  club-foot  exists  in  these  animals.     To  confirm  this  fact,  Dr.  E. 
G.  Brackett  examined  the  skeletons  of  several  monkeys  at  the  Boston 

!Brit.  Med.  Jour.,  1886,  vol.  ii.,  10. 
2  Archives  of  Medicine,  N.  Y.,  December  1st,  1882. 

3"Boylston  Prize  Essay,"  1887,  Boston  Med.  and  Surg.  Journal,  October  27th, 
1887. 


CLUB-FOOT. 


38? 


Natural  History  Museum,  and  found  that,  in  two  skeletons  of  monkeys 
examined,  the  angle  of  inclination  of  the  neck  of  the  astragalus  was  not 
over  20°,  and  in  two  others,  30°  and  35°.  The  articular  surface  faced, 
however,  in  each  case,  nearly  directly  forward,  being  set  on  the  neck  at 
an  angle.  The  effect  of  the  inclina- 
tion of  the  neck  was  to  broaden  the 
tarsus  at  this  point,  rather  than  to 
give  any  effect  of  talipes.  Although 
the  anthropoid  apes  are  not  club- 
footed,  they  are  quadrumana,  the  toe 
being  prehensile 
I  and  placed  oblique- 

ly inward,  instead 
of  being  parallel 
to  the  axis  of  the 
foot.  One  feature 
of  a  varus  distortion 
is  present,  and  prob- 
ably explains  the 
alteration  in  the 
neck  of  the  astrag- 
alus. '  The  conclu- 
sion to  be  derived 
from  all  this  is,  that 
it  may  be  said  that  we  are  entirely  ignorant  of  the  causation  of  club-foot, 
and  unable  to  give  a  reasonably  satisfactory  explanation  of  the  phenom- 
ena of  its  development. 

Symptoms. 


Fig.  345.  —  Infan- 
tile Talipes  Equino- 
varus. 


Fig.  346.— Resistant  Club-foot. 


Club-foot  gives  rise  to  great  inconvenience  in  walking.  In  uncor- 
rected cases,  however,  the  amount  of  skill  and  agility  patients  acquire  in 
locomotion  is  surprising,  even  though  the  deformity  remains  unchanged. 
Bursse  and  callosities  form  over  the  unprotected  portions  of  the  foot,  and 
may  inflame  and  cause  much  discomfort,  limiting  the  amount  of  the 
patient's  activity.  A  laxity  of  the  knee-joint  is  sometimes  developed  in 
consequence  of  club-foot,  and  some  change  in  the  shape  of  the  femur  and 
tibia  and  fibula  occurs.  No  alterations  of  importance  of  the  pelvis  take 
place,  though  there  is  undoubtedly  a  distortion  of  the  head  and  neck  of 
the  femur  which  causes  an  increased  awkwardness  in  gait. 

Although  club-foot  is  not  an  affection  which  interferes  with  activity 
or  usefulness,  the  deformity  is  so  marked  that  it  is  a  source  of  great 
mental  suffering.  Lord  Byron  presents  a  notable  instance,  and  Talley- 
rand is  said  to  have  entered  the  church  on  account  of  this  distortion. 


1  R.  W.  Parker  and  Shattuck :  Brit.  Med.  Jour.,  May  24th,  1884,  p.  998. 


388  ORTHOPEDIC   SURGERY. 

Dieffenbach  states  that  of  all  the  women  treated  by  hini  only  one  was 
married,  indicating  that  the  deformity  was  a  great  impediment  to  mar- 
riage. 

The  gait  of  these  patients  is  characteristic.  In  double  cases  the  feet 
are  lifted  one  over  the  other  as  a  step  is  taken,  giving  a  peculiar  appear- 
ance, and  perhaps  suggesting  the  popular  name  of  "  reel "  feet. 

The  distortion  presents  an  inward  twist  of  the  foot,  with  a  depressed 
position  of  the  outer  edge.  The  tendo  Achillis  is  firm  and  hard  to  the 
touch;  the  plantar  fascia  will  be  found  short  and  hard  on  palpation. 
The  front  of  the  foot  j>rojects  to  the  inside  of  the  vertical  axis  of  the 
leg,  the  tendinous  end  of  the  os  calcis  is  raised  and  turned  inward,  the 
leg  is  turned  outward,  and  the  head  of  the  astragalus  and  cuboid  project 
under  the  skin.  There  is  usually  atrophy  of  the  muscles  of  the  leg. 
The  external  malleolus  is  prominent  and  the  internal  malleolus  not  read- 
ily felt. 

Diagnosis. 

There  is  no  difficulty  in  recognizing  the  deformity  of  club-foot.  In 
infancy,  a  true  club-foot  is  sometimes  thought  to  exist  when  the  trouble 
is  simply  a  temporary  spasm  of  the  tibialis  muscles  which  turn  the  foot 
in.     This  passes  away  in  a  short  time  and  should  occasion  no  anxiety. 

The  deformity  may,  for  practical  purposes,  be  divided  into  three 
classes. 

First.  —  When  the  foot  can  be  brought  nearly  into  a  normal  position 
by  manipulation  with  the  hand. 

Second. — When  the  axis  of  the  foot  can  be  brought  into  the  line  of 
the  axis  of  the  leg,  but  the  foot  cannot  be  brought  to  a  right  angle. 

Third. — When  little  alteration  can  be  made  by  manual  manipulation 
of  the  foot. 

The  history  of  the  case  establishes  a  diagnosis  between  the  congenital 
and  non-congenital  forms  of  club-foot.  The  paralytic  form  can  be  recog- 
nized by  the  evidence  of  paralysis  of  the  muscles  on  the  anterior  and 
external  surface  of  the  leg.  Paralysis,  it  may  be  added,  js  the  only  com- 
mon cause  of  acquired  club-foot.  The  severity  of  cases  of  club-foot  can- 
not be  determined  always  by  the  apparent  distortion.  Cases  resembling 
each  other  in  outward  appearance  may  prove  less  or  more  difficult  of 
treatment.  As  a  rule,  however,  it  may  be  said  that  the  younger  the 
patient  the  less  resistant  the  deformity,  and  it  is  often  convenient  to 
consider  the  cases  as 

1st.  Infantile — i.e.,  infants  in  arms. 

2d.  Walking  cases — i.e.,  cases  in  young  children  in  which  the  feet 
have  been  walked  upon  before  the  deformity  has  been  corrected. 

3d.  Resistant  cases — i.e.,  those  which  have  resisted  treatment,  or 
in  which  treatment  has  been  inefficient. 


CLUB-FOOT.  38!) 

4th.  Neglected  cases,  those  so  neglected  that  but  little  successful 
treatment  has  been  attempted  until  the  feet  have  grown  for  years  in  a 
severely  distorted  position. 

Pkognosis. 

In  regard  to  the  prognosis  of  the  deformity,  it  may  be  said  that  the 
distortion  does  not  correct  itself,  and  if  left  uncorrected,  remains  the 
most  obstinate  of  malformations. 

The  deformity  is  one  which  is  essentially  curable ;  in  fact,  it  may  be 
said  that  it  is  always  curable,  provided  care  and  attention  can  be  given 
by  both  surgeon  and  nurse. 

The  amount  of  time  needed  for  treatment  varies  according  to  the 
method  employed.  Formerly  much  time  was  needed  in  the  treatment  of 
inveterate  cases,  but  since  the  introduction  of  open  incision  and  tarsal 
resection,  when  necessary,  correction  can  be  accomplished  in  a  short 
time. 

In  infantile  cases  the  time  required  for  correction  is  relatively  short, 
but  retentive  appliances  are  needed  for  a  longer  time.  In  fact,  it  may 
be  said  in  general,  the  older  the  cases  and  the  larger  the  foot  the  more 
difficult  the  correction,  but  the  less  the  danger  of  relapse  after  correction. 

In  regard  to  the  permanence  of  the  cure  and  the  danger  of  relapse,  it 
may  be  said  that  if  perfect  correction  is  attained  relapse  is  exceptional, 
if  moderate  care  is  used  in  the  employment  for  a  time  of  retentive  ap- 
pliance. ' 

But  it  must  be  borne  in  mind,  especially  in  the  case  of  young  chil- 
dren, not  only  that  the  correction  must  be  complete,  but  efficient  appli- 
ances for  keeping  the  proper  position  of  the  foot  in  walking  (ietentive  or 
walking  appliances  to  be  described)  must  be  worn  until  the  gait  and  atti- 
tude are  perfect.     In  club-foot  half -cures  are  practically  no  cures. 

Treatment. 

Treatment  of  club-foot  necessarily  varies,  in  a  measure,  according  to 
the  patient's  age  and  the  duration  and  nature  of  the  deformity;  but  it 
may  be  said  in  general  that  the  treatment  should  be  purely  mechanical, 
or  both  operative  and  mechanical. 

The  object  of  treatment  is  the  correction  of  the  distortion  and  the 
retention  of  the  foot  in  a  corrected  position  until  any  return  of  the  de- 
formity is  impossible. 

The  treatment  of  club-foot,  therefore,  requires. 

1.  A  rectification  of  the  misplaced  bones  and  a  lengthening  of  short- 
ened and  contracted  tissues. 

'Trans.  Am.  Orthop.  Assn.,  vol.  i.,  Club-foot 


390  ORTHOPEDIC   SURGERY. 

2.  A  retention  in  a  normal  position  until  the  abnormal  facet  of  the 
astragalus  and  the  other  tissues  become,  under  the  pressure  of  new  posi- 
tion, normal. 

The  first  of  these  can  be  done  by  mechanical  means,  stretching  or 
tearing  the  ligaments  and  tendons  (forcing  the  foot  into  shape),  or  with 
the  help  of  tenotomy  or  incision.      It  may  be  done  gradually  or  quickly. 

The  second  is  purely  a  mechanical  problem,  and  the  retentive  appli- 
ance should  be  worn  for  a  longer  or  shorter  time,  according  to  the  size  of 
the  distorted  bone  and  the  amount  of  the  distortion. 

The  rational  treatment  of  club-foot  is  of  comparatively  recent  date. 

Hippocrates  recommended  the  use  of  bandages  and  appliances  of 
copper,  lead,  or  leather  secured  to  the  skin  by  means  of  resin.  A  cord 
sewn  to  the  bandage  and  wound  around  the  foot  at  the  side  of  the  small 
toe  pulled  the  foot  outward  when  tightened.  This  appliance,  it  will  be 
seen,  resembles  the  one  recommended  by  Barwell.  Cheselden  recom- 
mended a  starch  bandage,  in  which  the  modern  plaster  bandage  finds 
its  prototype.  But  although  some  attempt  shave  always,  in  all  prob- 
ability, been  made  to  correct  club-foot,  there  is  no  reason  to  think  that 
in  earlier  times  any  success  followed  these  attempts.  The  custom  of 
distorting  the  feet  of  Chinese  ladies  is,  according  to  tradition,  a  relic  of 
an  edict  to  render  the  deformity  of  an  imperial  child  less  noticeable  by 
making  the  malformation  common — a  confession  of  the  impossibility  of 
cure. ' 

Even  in  later  times,  up  to  the  beginning  of  this  century,  the  treat- 
ment of  club-foot  had  fallen  into  such  discredit  that  success  was  not  re- 
garded as  possible.  Lord  Byron,  as  is  well  known,  abandoned  any  at- 
tempt at  correcting  the  deformity  after  being  treated  for  several  months 
by  Sheldrake. 

At  that  time  the  treatment  was  purely  mechanical,  but  the  introduc- 
tion of  tenotomy  brought  such  apparently  brilliant  results  that  this  pro- 
cedure was  regarded  as  of  itself  a  cure.  So  much  did  this  theory  pre- 
vail that  mechanical  treatment  came  to  be  regarded  as  of  secondary 
importance — a  view  not  held  or  advocated  by  surgical  authorities  on  the 
subject,  but  adopted  so  frequently  in  practice  that  many  unsuccessful  or 
partially  successful  cases  were  to  be  met.  Recently,  since  the  perfection 
of  the  details  of  antiseptic  and  aseptic  surgery,  more  radical  measures 
have  been  advocated,  such  as  open  incision,  osteotomy,  and  excision  of 
the  bones  of  the  tarsus  in  the  treatment  of  the  most  inveterate  cases. 

'This  explanation  of  the  Chinese  custom  is  not,  however,  universally  accepted, 
and  the  origin  is  certainly  obscure.  The  custom  was  present  as  early  as  the  sixth 
century  a.d.  and  the  deformity  is  referred  to  by  the  poets  as  indicating  beauty. 
This  idea  became  so  widespread  that  although  in  1664  a.d.  an  edict  was  published 
prohibiting  the  practice  of  distorting  the  feet,  owing  to  public  opinion  the  edict  was 
withdrawn.— Pall  Mall  Gaz.,  1889,  p.  1074. 


CLUB-FOOT.  391 

In  addition  to  this,  and  in  a  measure  counter  to  this  tendency,  the 
perfection  of  mechanical  appliances  and  of  correcting  methods  in  the  last 
decade  have  made  the  treatment  of  many  forms  of  club-foot  possible 
without  such  radical  measures,  or  even  in  many  instances  without 
tenotomy. 

It  is  hardly  necessary  to  consider  the  early  methods  of  correction  of 
club-foot,  which,  previous  to  the  time  of  Stromeyer,  were  entirely  me- 
chanical. Cures  seem  hardly  to  have  been  attained,  although  some  suc- 
cessful cases  are  reported.  In  all  probability  the  correction  was  incom- 
plete, and  the  results  to-day  would  not  be  considered  perfect  cures. 

At  the  present  time,  few  procedures  in  surgery  are  as  precise  in  their 
indications  and  as  certain  in  their  results  as  the  methods  for  the  correct- 
ing of  club-foot. 

The  correction  of  club-foot  should  be  divided  into  two  steps,  whether 
the  treatment  is  mechanical  or  operative. 

1st.   Correction  of  the  varus  deformity. 

2d.   Correction  of  the  equinus  deformity. 

In  other  words,  the  front  of  the  foot  should  be  twisted  out  and  after- 
ward be  raised.  This  will  be  found  of  practical  importance,  as  the  foot 
is  more  easily  twisted  before  than  after  the  equinus  deformity  is  over- 
come. In  addition  to  this,  as  there  is  invariably  some  alteration  in  the 
facet  of  the  astragalus,  some  mechanical  form  of  retention  of  the  corrected 
foot  is  necessary,  until  the  bone  adapts  itself  or  is  shaped  to  the  normal 
position  and  until  the  muscles  of  the  foot  and  leg,  altered  by  the  dis- 
tortion, recover  their  normal  tonicity.  In  short,  treatment  involves 
methods  of  correction  and  of  retention  of  the  corrected  position. 

The  methods  of  correction  are  either  mechanical,  or  a  combination  of 
both  mechanical  and  operative  means. 

The  operative  procedures  which  are  to  be  considered  in  treating  club- 
foot are : 

Tenotomy. 

Division  of  the  ligaments. 

Incision. 

Forcible  correction  and  excision. 

Mechanical  Correction.— T\\q  simplest  method  of  correction  is  by  the 
use  of  the  hands,  and  in  the  case  of  a  new-born  infant  with  club-feet 
the  mother  may  be  directed  to  manipulate  the  foot,  and  having  rectified 
the  deformity  by  gentle  force  several  times  daily,  to  hold  it  as  straight  as 
possible  for  a  minute  or  two  each  time.  The  writers  can  record  as  a  clin- 
ical curiosity  the  result  of  a  case  of  congenital  deformity  of  one  foot,  in 
a  child  under  a  year  old,  in  which  the  treatment  was  thoroughly  and  con- 
tinuously carried  out  by  a  nurse  and  mother  alternately  for  three  months. 
At  the  age  of  five  the  child  presented  an  equino-varus  foot  of  moderate 
type  as  to  deformity,  but  severe  as  to  resistance.     In  walking  the  weight 


392  ORTHOPEDIC   SURGERY. 

fell  chiefly  on  the  outer  side  of  the  sole;  the  foot  could  be  nearly  brought 
into  a  normal  position  by  the  use  of  moderate  force,  but  the  deformity 
could  not  be  over-corrected,  and  under  free  manipulation  possible 
from  anaesthesia  well-marked  distortion  of  the  neck  and  articular  facet 
of  the  astragalus  was  found ;  but  the  patient  presented  but  little  notice- 
able distortion  of  the  bared  and  none  of  the  clothed  foot.  Tenotomy 
of  the  tendo  Achillis  was  performed  and  the  patient's  walking  was  im- 
proved. 

Another  ready  method  in  correcting  club-foot  is  by  repeated  fixation 
in  a  plaster-of-Paris  bandage,  the  foot  being  held  as  nearly  in  a  corrected 
position  as  possible  at  each  application  of  the  bandage  until  the  bandage 
hardens.  The  bandage  should  reach  above  the  knee,  where  the  limb 
should  be  slightly  bent  to  prevent  the  plaster  bandage  (which  should  be 
renewed  every  two  or  three  weeks)  from  rolling  around  the  limb,  and  to 
prevent  the  child  from  kicking  it  off.  This  method  is  chiefly  applicable 
to  young  children  or  infants  and  can  be  made  efficacious. 

In  the  case  of  small  children  with  plump  legs,  and  in  resistant  cases, 
it  will,  however,  be  found  difficult  to  prevent  the  heel  from  being  drawn 
away  from  the  bandage,  and  stretching  of  the  tendo  Achillis  will  by  this 
method  be  tedious. 

This  method  has  the  disadvantage  of  being  tedious,  but  it  has  many 
advantages  in  being  a  practical  method,  readily  applied,  and  not  leaving 
details  of  application  to  the  patient's  parents.  It  is  evident  that  correc- 
tion in  this  way,  if  persistently  applied,  is  possible.  If  the  Chinese1  can 
produce  an  extreme  deformity  by  bandaging  the  children's  feet,  the  same 
method  could  be  employed  for  the  correction  of  deformity,  but  this  can 
be  done  only  at  the  expense  of  considerable  time  and  patience. 

Mechanical  (without  tenotomy)  correction  by  means  of  appliances  or 
elastic  straps  has  been  successfully  employed  in  very  young  cases.  The 
method,  however,  requires  much  persistence  on  the  part  of  the  surgeon, 
if  a  perfect  cure  is  expected. 

An  excellent  appliance  for  the  correction  of  infantile  club-foot  has 
been  devised  by  Beely.  A  slight  modification  of  this  will  be  seen  in  the 
accompanying  pictures  (Figs.  347,  348) .  It  is  light,  not  expensive,  and 
can  be  used  very  readily  by  the  mother  or  nurse.  The  method  has  been 
used  by  the  writers  chiefly  in  infantile  cases,  but  it  has  also  been  employed 
in  older  children. 

Two  steel  strips,  of  a  strength  varying  according  to  the  case,  are  cut 

1  Descriptions  of  the  method  of  the  Chinese  have  been  given  from  time  to  time 
by  travellers.  It  would  appear  to  consist  of  tight  bandaging  of  the  foot.  The  band- 
ages are  soaked  in  a  preparation  of  benzoin  and  are  wound  successively  around  the 
foot  as  tightly  as  possible.  The  toes  drop  off  occasionally  from  gangrene.  There  is 
great  pain  at  first,  but  subsequently  it  diminishes.  The  process  is  continued  for 
a  year  or  more. 


CLUB-FOOT. 


393 


of  proper  length  and  connected  by  an  ordinary  joint  allowing  free  motion. 
The  upper  end  of  B  is  connected  with  a  bent  strip  of  tempered  steel  long 
enough  to  encircle  half  the  patient's  pelvis,  a  leather  strap  F  completing 
the  circle.  The  lower  end  of  A  is  bent  so  as  to  pass  under  the  foot,  and 
has  two  buckles,  G  H,  to  receive  adhesive  plaster  on  the  patient's  leg, 
used  for  the  purpose  of  keeping  the  heel  well  in  the  appliance.  A  cross 
steel  strip  D,  padded,  passes  in  front  of  the  leg  above  the  ankle,  and 
with  a  strap  which  goes  behind  holds  the  leg  from  slipping  forward  or 


Fig.  347.  Fig.  348. 

Figs.  347  and  348.— Modified  Beely  Correcting  Appliance. 


backward.  A  steel  rod  C  projects  to  the  outer  side  of  the  foot.  It 
should  be  strong  enough  to  stand  ordinary  strain,  but  soft-tempered  and 
capable  of  being  bent  by  a  wrench;  it  furnishes  the  point  from  which  a 
pull  upon  the  deformity  can  be  made.  A  small  padded  plate,  1,  protects 
the  pressure  which  falls  upon  the  side  of  the  astragalus  and  os  calcis. 
The  limb  can  in  this  way  be  firmly  held  in  the  appliance.  The  child 
cannot  kick  it  off,  and  there  is  no  pressure  on  the  dorsum  of  the  foot  to 
cause  pain  or  sloughs. 

The  pull  upon  the  foot  is  effected  by  means  of  a  strip  or  strips  of 
adhesive  plaster  wound  about  the  foot  at  the  level  of  the  ball  of  the  toes, 
the  free  end  being  long  enough  to  reach  the  end  of  the  arm  C,  which  can, 
if  desired,  be  furnished  with  a  buckle,  into  which  the  webbing  sewn  on 
to  the  end  of  the  plaster  can  be  buckled,  or  the  plaster  alone  may  be 
wound  over  the  end  of  the  steel  rod.  If  it  is  desired  to  furnish  elastic 
tension,  elastic  webbing  can  be  used;  but  a  continued  pull,  increased  by 
tightening  as  the  deformity  is  corrected,  will  be  found  satisfactory. 


394  ORTHOPEDIC   SURGERY. 

To  protect  the  inside  of  the  great  toe  from  being  cut  by  the  pulling 
adhesive  plaster,  it  can  be  covered  by  a  strip  of  smooth  leather ;  and  to 
prevent  the  adhesive  plaster  from  slipping  back,  a  second  strip  of  plaster 
can  be  wound  close  to  the  first  on  the  proximal  side  of  the  foot. 

The  side  arm  C  is  to  be  bent  as  the  foot  is  corrected,  the  end  being 
placed  at  the  point  from  which  it  is  desired  that  the  pull  should  come. 
If  desired,  the  arm  C  can  be  connected  with  the  upright  ^i  by  means  of 
a  double  screw  joint,  so  that  motion  and  direction  of  the  arm  can  be  reg- 
ulated by  key.  This,  however,  increases  the  expense  of  the  appliance 
without  adding  to  the  efficiency.  Thorough  abduction  of  the  foot  should 
precede  elevation  or  correction  of  the  rotation.  Instead  of  the  plasters 
pulling  upon  the  foot,  bandages  can  be  used,  bandaging  the  foot  to  the 
arm  C.  If  holes  are  cut  in  the  stocking  and  shoe  so  that  the  free  ends 
of  an  adhesive  plaster  may  pass  through,  the  appliance  can  be  used  with 
the  patient  wearing  shoes  and  stockings. 

The  efficacy  of  the  appliance  depends  chiefly  on  the  handiness  used  in 
applying  it.  No  especial  skill  is  required  to  tighten  the  straps;  and 
this  can  easily  be  left  to  the  nurse,  with  the  direction  that  the  side  straps 
should  be  kept  as  tight  as  possible.  The  adhesive  plaster  should  be 
changed  every  three  or  four  days,  and  this  can  be  done  by  the  nurse 
without  difficulty.  Some  skill  is  required  in  designing  and  fitting  the 
appliance,  it  being  essential  that  the  foot  and  leg  are  well  held  in  it,  and 
that  the  steel  is  strong  enough. 

Correction  by  Means  of  Straps  and  by  an  Elastic  Force. — The  use  of 
an  elastic  force  to  overcome  contraction  can  be  employed  in  the  correction 
of  club-foot  as  of  other  deformities.  It  has  been  recommended  by  Davis 
and  Barwell  and  Sayre. 

Various  appliances  have  been  devised  to  employ  elastic  correction,  and 
on  the  theory  that  the  elastic  force  supplemented  the  weaker  muscles, 
the  method  was  regarded  as  physiological ;  but  though  the  method  will 
be  found  of  use  in  some  of  the  lighter  cases,  yet  it  has  not  seemed  to  the 
writers  superior  to  other  ways  of  mechanical  correction. 

The  amount  of  the  force  can  in  a  measure  be  increased  by  securing 
the  foot  to  a  flat  thin  board,  longer  than  the  foot  and  wider  at  the  outer 
edge,  and  attaching  the  elastic  straps  to  the  farthest  points  of  the  board; 
but  even  with  the  advantage  of  mechanical  leverage  thus  obtained  the 
treatment  demands  time  and  is  an  annoyance  which  can  be  avoided  by 
tenotomy. 

Thomas,  of  Liverpool,  and  Taylor,  of  New  York,  have  both  demon- 
strated that,  if  the  foot  can  be  prevented  from  twisting  or  rolling  by  any 
appliance,  the  weight  in  walking  in  a  child  of  any  size,  if  thrown  fairly 
upon  the  foot,  will  act  in  correcting  the  equinus  deformity.  To  do  this 
effectually  the  knee  should  be  kept  from  bending.  This  method  will  not 
be  efficient  in  cases  of  extreme  equinus,  but  it  will  be  found  a  help  in 


CLUB-FOOT. 


395 


cases  with  moderate  contraction.  The  same  may  be  said  of  the  method 
of  mechanical  stretching  of  the  tendons  by  means  of  appliances  furnished 
with  geared  joints  moved  by  a  key.  More  speedy  and  efficient  means  of 
correction  are  now  available  than  when  tenotomy  was  considered  a  grave 
operation, 

Combined  Operative  and  Mechanical  Method  of  Treatment. — A  com- 
bination of  operative  and  mechanical  methods  of  treatment  is  at  present 
the  most  common  mode  of  treating  club-foot  of  all  ages.  The  operative 
interference  most  frequently  resorted  to  is  tenotomy  and  subcutaneous 
division  of  the  fascise  or  ligaments. 

Tenotomy. — Delpech,  guided  by  accidental  section  and  ruptures  of  the 
tendon,  was  the  first  to  define  the  indications  for  a  scientific  tenotomy, 
and  thus  made  an  important  advance  in  the  treatment  of  club-foot. 
Stromeyer,  Bouvier,  Guerin,  Little,  and 
Adams  have  made  the  operation  popular 
and  within  the  reach  of  every  surgeon. 

The  tendons  may  be  divided  by  enter- 
ing the  tenotome  under  the  skin  and  cut- 
ting the  tendon  from  without  inward,  or 
by  passing  the  tenotome  under  the  tendon 
and  cutting  outward.  The  advantage  of 
the  former  is  that  there  is  no  danger  of 
making  through  the  slit  of  the  tendon  a 
large  skin  incision.  There  is,  however, 
danger  of  incomplete  cutting  of  the  ten- 
don.     Bouvier  calls  the  two  methods  of 

IIS. 

procedure  sub-  and  supratendinous  sec- 
tion, and  according  to  this  surgeon  a  choice  is  a  matter  of  indiffer- 
ence, but  the  subtendinous  method  is  sometimes  to  be  preferred  as 
the  most  simple  in  its  execution  and  one  permitting  complete  section 
of  the  tendon  without  risking  the  skin.  The  supratendinous  method  is 
to  be  preferred  when  the  tendons  are  not  very  salient,  as  in  young  chil- 
dren, or  in  tendons  close  to  the  bone  or  in  the  neighborhood  of  vessels 
and  important  nerves.  The  tendon  which  is  most  frequently  divided  in 
equino-varus  is  the  tendo  Achillis. 

Section  of  the  Tendo  Achillis. — The  patient  should  lie  upon  his  face 
and  an  assistant  should  hold  the  foot ;  the  surgeon,  having  made  a  longi- 
tudinal fold  of  the  skin,  enters  the  knife  parallel  to  the  border  of  the 
tendon,  passing  the  tenotome  flatwise  between  the  tendon  and  the  skin. 
This  having  been  done,  the  blade  of  the  knife  is  turned  toward  the  pos- 
terior surface  of  the  tendon  and  the  assistant  raises  the  end  of  the  foot 
so  as  to  stretch  the  tendo  Achillis  slightly.  The  left  index  finger  presses 
on  the  skin  over  the  back  of  the  tenotome,  and  in  this  way  the  sensation 
of  the  cutting  of  the  tendon  can  be  felt. 


Fig.  349.— Position  of  Hands  in  Hold- 
ing Foot  for  Tenotomy  of  Tendo  Achil- 


396  ORTHOPEDIC   SURGERY. 

The  only  precaution  necessary  is  to  be  assured  that  the  tendon  is 
completely  divided.  When  the  operation  is  done,  the  extravasated  blood 
is  squeezed  out  of  the  opening  and  a  small  amount  of  aseptic  cotton  is 
placed  over  the  wound.  The  operation  should  be  done  aseptically  and 
an  aseptic  dressing  applied. 

Section  of  the  Tibialis  Posticus.  —  Section  of  the  tibialis  posticus  is 
done  in  the  following  way :  If  the  muscle  is  divided  in  the  leg,  the  foot 
is  placed  on  its  external  border.  The  surgeon  divides  the  skin  by  means 
of  a  pointed  tenotome  2  cm.  above  the  tip  of  the  internal  malleolus  and 
on  a  vertical  line  situated  half-way  between  the  posterior  border  of  the 
malleolus  and  the  corresponding  border  of  the  tendo  Achillis.  The  teno- 
tome should  be  directed  perpendicularly  downward  to  the  depth  of  1  or 
1.5  cm.  Then  the  handle  of  the  instrument  should  be  turned  so  as  to 
describe  the  arc  of  a  circle  and  the  tendon  divided  vertically  inward. 
This  having  been  done,  the  tenotome  is  withdrawn  and  a  blunt-pointed 
one  inserted.  This  should  be  directed  so  as  to  pass  behind  and  under 
the  tendon  of  the  tibialis  posticus,  and  then  it  is  sufficient  to  turn  the 
cutting  edge  forward  and  to  move  the  instrument  gently  forward  and 
back,  while  the  assistant  at  the  same  time  turns  the  foot  forcibly  in  the 
direction  of  abduction. 

If  the  incision  is  made  too  near  the  malleolus,  the  internal  saphenous 
vein  and  nerve  may  be  cut.  If  the  incision  is  made  too  near  the  tendo 
Achillis,  there  is  danger  of  dividing  the  tendon  of  the  long  flexors  of  the 
toes  and  the  posterior  tibial  artery  and  nerve.  Bonnet  thinks  he  has 
wounded  this  artery  more  than  once,  but  without  serious  injury.  To 
avoid  this  possibility,  Velpeau  advised  cutting  the  tendon  of  the  tibialis 
posticus  on  the  foot  from  a  line  extended  from  the  top  of  the  internal 
malleolus  to  the  scaphoid,  but  this  is  not  easily  done  in  infants. 

The  writers  can  record  the  puncture  of  the  posterior  tibial  artery  by 
the  point  of  a  tenotome  and  the  formation  of  a  small  aneurism  which  re- 
quired ligation,  but  caused  no  subsequent  annoyance. 

The  Tendon  of  the  Tibialis  Anticus. — The  tendon  of  the  tibialis  anti- 
cus  is  divided  more  easily.  For  this  purpose  it  is  sufficient  to  be  guided 
by  the  prominence  of  the  tendon  put  on  a  stretch  by  abducting  the  foot. 
To  avoid  the  wounding  of  the  deep  parts,  it  is  better  to  enter  the  teno- 
tome under  the  tendon. 

Division  of  the  Plantar  Fascia. — It  is  often  necessary  to  divide  also 
the  plantar  fascia,  preferably  before  division  of  the  tendo  Achillis,  as 
the  latter  acts  as  a  means  of  support  for  stretching  the  foot  when  the 
plantar  fascia  is  divided.  The  plantar  fascia  is  divided  in  the  same 
way  that  the  tendons  are  incised.  The  most  prominent  portion  of  the 
fascia  is  the  point  of  election  for  subcutaneous  incision.  The  fascia,  it 
must  be  borne  in  mind,  is  not  a  narrow  band,  but  a  broad  ligament 
needing  a  long  subcutaneous  incision.     The  tenotome  should  be  inserted 


CLUB-FOOT. 


397 


on  the  inner  side  of  the  sole  nearly  half-way  between  the  os  calcis  and 
the  ball  of  the  foot,  but  nearer  to  the  os  calcis.  The  tenotome  is  to  be 
pushed  subcutaneously  nearly  across  the  sole,  the  edge  of  the  knife  turned 
toward  the  fascia,  and  the  knife  drawn  across  the  fascia,  which  will  be 
felt  to  give  way  as  it  is  divided;  an  assistant  should  make  upward  press- 
ure upon  the  ball  of  the  foot,  in  order  to  put  the  fascia  on  the  stretch. 
As  the  artery  lies  deeply,  there  is  no  danger  of  injuring  it,  if  ordinary 
care  is  used. 

The  tenotomes  used  should  be  strong  at  the  neck,  and  the  cutting 
edge  should  not  be  too  long,  as  the  skin  is  necessarily  divided  if  they  are 
too  long;  a  cutting  edge  is  used  in  operating  on  infantile  cases,  which 


Fig.  350.—  Different  Forms  of  Tenotomes. 

require  a  much  smaller  instrument.  Tenotomes  should  be  of  two  sorts, 
one  with  a  short,  pointed  end,  for  thrusting  into  the  skin  and  under  the 
tendon,  and  a  blunt-pointed  one  which  can  follow  where  there  is  danger 
of  wounding  an  artery  by  a  sharp  point.  Curved  tenotomes  are  sometimes 
of  use,  especially  for  division  of  the  scapho-astragaloid  ligament. 

Tenotomes  as  furnished  by  instrument  makers  are  ordinarily  much 
too  large,  and  though  serviceable  in  myotomy,  are  better  for  tenotomy  in 
children  if  smaller  than  is  indicated  in  the  accompanying  cut.  The  neck 
should  be  strong,  as  the  breaking  of  the  tenotome  in  the  wound  (an  acci- 
dent which  once  happened  in  the  experience  of  the  writers)  gives  annoy- 
ance. 

The  Repair  of  Divided  Tendons. — The  reparative  process  of  divided 
tendons  has  been  made  a  subject  of  numerous  investigations,  since 
Hunter's  original  experiments  in  1767,  and  has  been  studied  with  much 
care  by  Mr.  Adams,  and  later  by  Tubby.1  When  a  tendon  is  divided, 
the  cut  ends  are  separated  to  a  variable  extent,  depending  upon  the  re- 
traction of  the  muscle  to  which  it  belongs,  upon  the  position  in  which 
the  limb  is  placed,  and  upon  the  surrounding  attachments  of  the  tendon. 


»"Orth.  Surgery,"  1806,  p.  321. 


39 S  ORTHOPEDIC   SURGERY. 

Extending  beneath  the  ends  of  the  tendon  is  its  tubular  sheath  of  connec- 
tive tissue,  and  it  is  this  which  chiefly  furnishes  the  reparative  material. 

The  sheath  becomes  vascular  and  succulent,  and  after  the  absorption 
of  any  blood  that  may  have  been  effused  within  it,  the  interval  between 
the  divided  ends  of  the  tendons  becomes  filled  with  lymph,  which  gradu- 
ally becomes  fibrillated  and  forms  a  firm  bond  of  union  between  them. 

The  new  material  so  closely  resembles  the  old  tendon  and  is  so  inti- 
mately blended  with  it  that  for  a  time  it  would  be  difficult  to  distinguish 
them,  except  for  a  certain  transluceucy  which  is  possessed  by  the  former, 
and  is  not  natural  to  the  latter.  By  this  means  the  divided  tendon  is 
increased  in  length  to  the  extent  of  the  interval  by  which  its  ends  are 
separated,  and  elongation  will  vary  according  to  the  amount  of  separation. 

If  after  the  operation  treatment  is  carried  out  with  ordinary  care  and 
skill  on  a  healthy  subject,  a  perfect,  useful  muscle  of  the  normal  length 
is  obtained. 

Adhesions  may,  and  doubtless  often  do,  form  between  the  divided 
tendons  and  the  surrounding  structure,  but  in  ordinary  cases  they  are  not 
of  consequence,  for  they  give  way  to  the  manipulation  of  use  of  the  foot, 
and  do  not  interfere  with  the  function  of  the  muscle. 

Much  undeserved  opprobrium  for  a  time  fell  upon  the  procedure  of 
tenotomy.  In  half -cured  and  relapsed  cases  atrophy  and  functional  disa- 
bility of  the  muscles  will  be  found ;  but  there  is  no  evidence  to  demon- 
strate that  tenotomy,  when  properly  performed,  exerts  an  unfavorable  in- 
fluence upon  the  muscle. 

Division  of  the  Ligaments. — Division  of  the -ligaments  has  been  re- 
garded as  useful  by  many  operators.  Parker  and  Shattuck  have  called 
especial  attention  to  the  importance  of  this  use  of  the  tenotome. ' 

For  division  of  the  astragalo-scaphoid  ligament,  the  skin  and  soft 
tissues  should  be  punctured  down  to  the  bone  by  the  insertion  of  the 
tenotome.  It  should  then  be  inserted  in  front  of  the  internal  malleolus 
and  pushed  directly  to  the  underlying  bone,  and  swept  subcutaneously 
around  the  bone,  keeping  close  to  it.  The  knife  should  be  kept  between 
the  skin  and  ligaments,  and  the  latter  divided  by  a  sawing  motion  of  the 
tenotome.  This  division,  if  satisfactorily  and  thoroughly  made,  may 
serve  in  certain  cases  as  a  substitute  for  the  division  of  the  tibialis 
tendons. 

The  calcaneo-cuboid  ligament  should  also  be  divided  in  severe  cases. 
The  tenotome  should  be  inserted  a  short  distance  behind  the  head  of  the 
fifth  metatarsal  bone,  near  the  articulation  of  the  os  calcis  and  cuboid, 
which  can  be  felt  on  palpation.  The  sharp-pointed  tenotome  should  be 
inserted  to  the  bone,  and  then  by  careful  motion  the  whole  ligament 
should  be  divided. 

•London  Path.  Soc,  British  Med.  Jour.,  1886,  vol.  ii.,  p.  10. 


CLUB-FOOT.  399 

The  age  at  which  patients  should  be  operated  on  is  a  matter  of  judg- 
ment and  should  depend  upon  the  child's  condition  and  nutrition. 

The  reputed  growth  of  a  child's  foot  is  indicated  by  the  measurements 
of  Quetelet  and  Langer.  A  child  3  months  old  has  a  foot  75  to  85  nun. 
long,  at  6  months  101  mm.,  at  1  year  107  mm.,  at  15  months  112  nun., 
at  18  months  110  mm.,  at  20  months  119  mm.,  and  at  21  months  122  nun. 
That  is  to  say,  the  foot  increases  with  less  rapidity  the  older  the  child 
grows,  and  if  the  foot  is  left  to  itself  the  deformity  greatly  increases  in 
the  first  months  of  life.  It  is  therefore  rational  to  claim  that  the  sooner 
the  foot  is  corrected  the  better,  provided  the  patient's  general  condition 
is  satisfactory,  and  that  treatment  is  not  liable  to  be  interrupted  by  inter- 
current infantile  disorders ;  practically,  treatment  should  be  undertaken 
as  soon  as  an  infant  is  nursing  well  and  is  in  reasonable  health. 

Subcutaneous  tenotomy  of  all  the  parts  which  obstruct  the  complete 
restoration  is  performed.  This  in  most  cases  consists  of  division  under 
an  anaesthetic  of  the  plantar  fascia,  the  tendons  of  the  tibialis  anticus 
and  posticus,  the  ligament  of  the  scapho-astragaloid  joint,  and  last,  the 
tendo  Achillis.  After  the  tenotomy  of  the  first  three  the  foot  is  forci- 
bly corrected  by  the  hand,  and  a  division  of  the  resisting  parts  carried 
to  such  a  point  that  the  foot  can  be  easily  brought  beyond  the  normal 
plane,  after  which  tenotomy  of  the  tendo  Achillis  is  done  and  the  foot 
placed  in  plaster. 

These  plaster  bandages  are  left  on  for  an  interval  of  from  ten  days 
to  three  or  four  weeks.  In  case  the  restoration  has  not  been  perfect,  as 
sometimes  happens  with  more  resistant  feet,  it  is  well  to  remove  the 
plaster  at  the  end  of  ten  days  or  two  weeks  and  apply  the  shoes  (to  be 
described),  reapplying  the  apparatus  every  two  or  three  weeks.  In  this 
way,  before  complete  consolidation  has  taken  place,  a  certain  amount  of 
gain  can  be  made  and  over-correction  be  obtained  at  the  end  of  a  few 
weeks  which  at  first  was  impossible.  If,  however,  the  restoration  has 
been  complete  it  is  better  to  keep  the  bandages  on  for  from  six  to  twelve 
weeks  in  order  that  the  foot  may  not  be  disturbed  from  its  over-corrected 
position.  When  the  bandages  are  removed  great  care  should  be  taken 
that  the  foot  is  not  allowed  to  drop  from  its  over-corrected  position,  and 
thus  make  traction  on  the  ligaments  and  soft  parts  in  which  contraction 
is  desired. 

When  the  plaster  bandages  are  removed  a  retention  appliance,  to  be 
described  later,  is  to  be  used  so  long  as  there  is  any  tendency  to  an  incor- 
rect position. 

The  permanence  of  the  correction  depends  on  the  establishment  of 
an  accurate  balance  of  the  antagonism  of  muscles  and  other  soft  parts 
when  the  foot  is  in  normal  position.  The  after-treatment  by  retention 
must  be  persisted  in  until  the  child  is  able,  without  special  effort,  to 
walk  with  the  foot  in  a  natural  position,  otherwise  a  relapse  will  occur. 


400  ORTHOPEDI€    SURGERY. 

In  resistant  cases  the  following  radical  measures  have  been  employed: 

1st.   Open  incision. 

2d.   The  use  of  extreme  force. 

3d.   Tarsal  osteotomy. 

4th.   Tarsal  resection. 

The  chief  difficulty  is  in  obstinate  cases  to  stretch  the  contracted 
tissue  on  the  concave  side  of  the  distortion.  Acting  on  this  belief,  Dr. 
A.  M.  Phelps  has,  by  a  direct  open  incision  on  the  inner  and  plantar 
surface,  corrected  severe  cases,  and  has  favored  this  method  of  treatmeut. 

The  advantage  of  open  incision  in  club-foot  is  the  facility  of  complete 
and  thorough  division  of  all  the  soft  tissues  to  the  bone.  The  method  by 
which  this  is  done  is  as  follows .  The  skin  is  divided  along  the  inner  side 
of  the  foot,  from  the  tip  of  the  malleolus  well  down  on  the  inner  edge  of 
the  first  metacarpal  bone.  After  the  skin  is  incised,  the  other  tissues 
are  cut  with  care,  using  a  director  if  necessary.  The  insertion  of  the 
tibialis  tendon  is  found  and  cut  across.  The  artery  can  be  spared  by 
careful  dissection,  but  if  necessary  it  can  be  divided  and  tied.  The 
plantar  fascia  on  the  sole  of  the  foot  should  be  divided  by  the  use  of  a 
tenotome,  or  long  thin  knife.  A  cross  incision  toward  the  sole  of  the 
foot  from  the  middle  of  the  long  incision  is  sometimes  necessary,  but  it 
is  desirable  to  avoid  this  if  possible.  A  triangular  incision  instead  of 
the  cross-cut  of  the  skin  and  fascia  is  recommended  by  Jonas'  to  di- 
minish the  gap  after  correcting  the  foot. 

Even  if  tenotomy  and  thorough  open  incision  are  done  a  certain  amount 
of  resistance  remains  from  the  interosseous  ligament  connecting  the  tarsal 
bones.  Considerable  force  is  often  necessary  to  bring  the  foot  into  an 
over-corrected  position.  This  can  be  done  either  by  manual  force  or  by 
the  aid  of  mechanical  force.  Several  wrenches  for  this  purpose  have  been 
devised ;  that  of  Thomas  is  the  simplest  and  is  sufficiently  efficient  when 
no  bone  obstruction  exists.  The  foot  is  then  brought  into  as  normal  a 
position  as  possible,  thorough  aseptic  dressings  are  applied,  and  the  foot 
is  then  fixed  in  a  plaster-of -Paris  bandage  reaching  above  the  knee  and 
holding  the  well-padded  and  aseptically  dressed  foot  in  an  over-corrected 
position.  If  the  dressing  is  provided  with  efficient  protectors  and  suffi- 
cient dressings,  no  change  in  the  bandage  need  be  made  for  a  fortnight  or 
longer.  If  necessary,  however,  a  window  can  be  cut  in  the  plaster  over 
the  wound  and  the  dressings  changed.  After  the  plaster  of  Paris  is 
discarded  the  retention  shoe  is  to  be  worn. 

Of  this  method  it  may  be  said  that  healing  by  organized  blood  clot 
is,  to  those  who  are  proficient  in  aseptic  surgery,  almost  certain,  and  the 
method  is  therefore  free  from  danger. - 


'Jonas.  Annals  of  Surgery,  April,  1897,  449. 
'2Phillipson:  Deut.  Zeitschr.  f.  Chir.,  xxviii. 


CLUB-FOOT. 


401 


la  applying  the  bandages,  it  is  of  course  important  that  the  foot 
should  be  held  in  a  corrected  position,  or  an  over-corrected  position,  until 
the  plaster  becomes  hard,  as  no  further  correction  can  take  place  undex 
the  bandage.  In  the  majority  of  cases  perfect  correction  or  over-correc- 
tion is  possible,  and  the  foot  can  be  held 
in  proper  position  for  the  application  of 
the  fixation  bandage  without  much  force. 

Krauss,  as  an  aid  to  support  by 
plaster  bandages,  makes  use  of  a  wooden 
sole  plate  with  a  steel  upright  on  the  in- 
ner side  of  the  leg  and  an  arrangement  for 
increasing  the  pressure  for  the  inner  side 
of  the  metatarsal  and  great  toe.  The  appli- 
ance is  covered  with  thick  felt,  and  the  foot 
and  ankle  are  secured  to  the  wooden  sole 
plate  by  means  of  a  plaster-of-Paris  band- 
age applied  over  a  stocking,  and  without  much  cotton  applied  to  the  foot. 

The  writers  would  agree  in  the  statement  that  forcible  rectification  is 
able  to  correct  and  cure  the  severest  forms  of  club-foot,  but  they  have 
found  mechanical  correction  more  reliable  than  simple  manual  force. 

The  accompanying  cuts  (Figs.  352,  353,  and  354)  indicate  relapsed  and 
resistant  cases  of  congenital  club-foot.     The  boy  was  fourteen  years  of 


Fig.  351.— Foot  before  correction. 


Fig.  352.— Foot  before  Correction. 


•  ft' 

Fig.  353.  fig.  &>4. 

Figs.  a53  and  a54— Foot  after  Correction 


age;  the  foot  was  corrected  at  one  sitting,  necessitating  the  use  of  a 
plaster  bandage  to  the  corrected  foot  for  two  months.  A  walking  ap- 
pliance was  furnished  and  no  further  treatment  other  than  occasional 
inspection  for  six  months  was  necessary,  and  the  cure  had  remained 
permanent  when  last  heard  from,  three  years  later. 
26 


402 


ORTHOPEDIC   SURGERY. 


The  cast  of  the  girl's  foot  was  taken  at  the  age  of  ten.  Two  rectifi- 
cations were  needed  and  a  direct  treatment  of  four  months.  The  draw- 
ings, from  a  photograph,  indicate  the  condition  of  the  feet  when  the  child 
was  thirteen,  no  appliance  having  been  worn  for  two  years  (Figs.  351, 
355,  and  356). ' 

Operation  ypon  the  Bones. — When  but  a  slight  amount  of  osseous 
distortion  is  present  forcible  correction  aided  by  tenotomy  or  open  inci- 


FIG.  355. 

sion  will  be  sufficient  to  overcome  the  deformity,  but  in  the  more  resist- 
ant cases  changes  in  the  shape  of  the  tarsal  bones  forming  the  medio- 
tarsal  joint  prevent  perfect  cure,  and  operation  upon  the  bones  is 
necessary. 

Excision  of  the  Tarsus.* — Dr.  Little,  of  London,  was  the  first  to  sug- 
gest removal  cf  a  portion  of  the  tarsus  (the  cuboid  bone)  as  a  means  of 
shortening  the  treatment  in  "inveterate  varus."3  This  was  done,  in 
1854,  by  Mr.  Solly,  of  St.  Thomas'  Hospital,  at  the  recommendation  of 
Dr.  Little;   the  result  was  less  successful  than  was  anticipated,  owing, 

'Wolff  uses  the  silicate  bandage  as  a  walking-appliance,  but  it  is  manifestly 
more  cumbersome  and  unsightly,  and  therefore  less  useful,  than  the  Taylor  varus  shoe. 
aH.  A.  Wilson:  Orth.  Trans.,  vol.  vi.,  159. 
3" Practical  Observations  on  the  Treatment  of  Club-Foot,"  third  edition,  p.  305. 


CLUB-FOOT. 


403 


apparently,  to  the  difficulty  encountered  in  maintaining  the  corrected 
position  of  tho  foot  by  means  of  the  appliances  used.  The  patient  re- 
covered from  the  operation.1  Mr.  Lund  8  removed  the  astragalus  in  a 
similar  case  with  success.  The  details  have,  however,  not  been  given 
with  sufficient  accuracy  to  justify  a  clear  opinion  as  to  the  perfection  of 
the  cure.     Dr.  Mason,  of  New  York,  was  obliged  to  amputate  in  a  case  in 


Fig.  356.— Result  Two  Years  after  Apparatus  was  Left  Off     Girl  of  thirteen.    Resistant  club-foot. 

which  he  had  unsuccessfully  excised  the  astragalus3  and  a  portion  of  the 
external  malleolus.  Verbelzi  successfully  dissected  out  the  astragalus  in 
a  case  of  congenital  club-foot  in  a  child  five  and  one-half  year3  old.4 
The  exact  details  it  has  not  been  possible  to  find. 

Mr.  Lund  showed  before  the  London  Clinical  Society  a  case  in  which 
he  had  successfully  removed  the  astragali  in  double  congenital  talipes. 
The  boy  was  able  to  walk  about  readily.  The  astragalus  was  excised 
(after  an  incision  through  the  soft  parts)  by  means  of  a  gouge  and  a 


•Adams:  "Club-Foot,"  second  edition,  Philadelphia,  p.  251. 

2  British  Medical  Journal,  October  19th,  1872. 

3  New  York  Medical  Record,  July  14th,  1877. 

4  Centralblatt  f.  Chirurgie,  Nv.  24,  1877. 


404 


ORTHOPEDIC   SURGERY. 


short  curved  hook,  with  a  cutting  edge  on  its  concavity.     Mr.  Thomas 
Smith  and  Prof.  John  Wood  have  also  performed  the  operation  success- 

(I  J>  c 


Fig.  357.— Axis  of  Medio-tarsal  Joint  in,  a,  Club-foot ;  b,  normal  foot ;  c,  club-foot  partly  corrected, 
showing  wedge  to  be  removed  before  correction  is  complete. 

fully.1    Mr.  Davy2  operated  in  three  cases  by  removing  simply  the  cuboid 
bone,  and  in  three  cases  by  excising  a  wedge-shaped  piece  from  the  tarsal 


Fig.  358.  FIG.  359. 

Fig.  358.— Imprint  of  Foot  of  a  Child  Sixteen  Years  Old.    Treated  when  one  year  old  for  congenital  club- 
foot. 
Fig,  359.— Imprint  of  Normal  Foot. 


1  Lancet,  March  16th,  1878,  p.  389. 

■'Lancet,  February  14th,  1888;  Lancet,  March  16th,  1878,  p.  388;  British  Medi- 
cal Journal,  December  15th,  1877. 


CLUB-FOOT. 


405 


arch.  Death  from  septicaemia  occurred  in  one  case.  In  the  others  re- 
covery took  place,  and  from  the  report  the  cases  progressed  favorably. 
Davies  Colley  operated  by  resection  of  the  tarsal  bones  on  a  child  twelve 
years  old;  ten  days  after  the  operation  on  the  second  foot,  and  twelve 
weeks  after  the  first  operation,  the  patient  was  able  to  walk  about  with- 
out any  apparatus.  Two  months  later,  when  re-examined  (no  apparatus 
having  been  worn  in  the  interval),  the  foot  was  found  in  good  position, 
the  boy  treading  on  the  whole  of  the  sole.  The  patient  could  walk,  hop, 
and  jump.      Six  months  later  he  was  able  to  walk  eight  miles.' 

Konig,2  E/upprecht, a  Mensel,4  and  others  report,   respectively,   three, 
five,  and  five  operations  of  resection  of  the  tarsus  for  severe  club-foot. 


Fig.  360.— From  Photograph  of  a  Woman,  Thirty-five  Years  Old,  Suffering  from  Congenital  Club-foot. 

All  are  mentioned  as  successful  with  the  exception  of  one  under  the  care 
of  Konig,  in  which  death  occurred  ten  days  after  the  operation.  At  the 
autopsy  it  was  found  that  the  patient  had  been  suffering  from  ulcerative 
endocarditis,  with  valvular  disease  of  the  heart,  and  with  pathological 
changes  in  the  lungs. 5 

The  methods  introduced  may  be  grouped  as  follows : 

1.  Eemoval  of  the  cuboid  alone. 

•2.   Removal  of  the  astragalus  alone. 


1  Medico-Chirurgical  Transactions,  second  series,  vol.  xliii.,  18"' 

2  Centralblatt  f.  Chirurgie,  1880,  No.  13. 
*Ibid.,  March  13th,  1880. 

4  Centralblatt  f.  Chirurgie,  No.  11,  1880. 
sPoore:  Annals  of  Surgery,  March,  1886,  p.  206. 


406 


ORTHOPEDIC   SURGERY. 


.'}.   Removal  of  the  astragalus  and  cuboid  and  scaphoid. 

4.   Section  cf  the  neck  of  the  astragalus. 

f>.  Removal  of  tho  astragalus  and  the  external  malleolus. 

6.  Osteotomy  cf  the  lower  end  of  the  tibia  and  fibula. 

7.  Wedge-shaped  resection  of  the  tarsus. 

8.  Osteotomy  of  the  os  calcis. 

Removal  of  the  cuboid  or  astragalus  alone  is  insufficient,  as  in  resist- 
ant cases  of  club-foot  the  os  calcis  is  also  involved  while  the  cuboid -is 


Fig.  361.— The  Same  Foot  One  Year 
after  Forcible  Correction. 


FIG.  362. 


-Same  Foot  One  Year  after  Forcible 
Correction. 


but  slightly  distorted,  and  the  chief  distortion  of  the  astragalus  is  at  the 
medio-tarsal  articulation. 

A  wedge-shaped  excision  of  the  tarsus  sacrifices  bone  unnecessarily 
and  is  therefore  unscientific,  and  osteotomy  of  the  lower  end  of  the  tibia 
and  fibula  is  neither  sufficient  nor  scientific.  Correction  by  wedge-shaped 
resection,  however,  and  also  by  removal  of  the  astragalus  can  give  satis- 
factory, though  not  perfect  results. 

The  illustration  represents  a  satisfactory  result ;  the  condition  prior  to 
operation  in  the  instance  of  a  boy  of  fourteen  is  indicated  in  the  drawings 
from  the  casts  2  and  4  (Fig.  373),  and  the  result  of  the  operation  by  drawing 
from  the  casts  1  and  3.     Both  feet  were  operated  upon  and  the  functional 


CLUB-FOOT. 


407 


result  may  be  determined  by  the  illustration  reproduced  from  the  photo- 
graph (Fig.  373).     It  may  be  added  that  the  hoy  was  seen  at  the  age  of 
nineteen  and  had  been  able  for  several  years  to  engage  in  an  active  oc- 
cupation, and  was  able  to  walk  without  cane 
or  ankle  appliance  five  or  ten  miles. 

Astragaloid  Osteotomy. — An  examination 
of  the  anatomy  of  resistant  club-foot  shows 
that  the  facet  of  the  astragalus  in  the 
astragalo-scaphoid  articulation  is  on  the 
side  instead  of  in  front.  There  is  also 
some  obliquity  of  the  neck  of  the  astraga- 
lus. If  this  obstruction  of  the  bone  can 
bo  corrected  and  the  front  of  the  foot 
brought  into  place,  there  would  be  no  tend- 
ency to  relapse. 

It  is  essential,  in  every  inveterate  case 
of  club-foot,  that  if  the  foot  is  to  be  un- 
folded, the  shortened  tissues  in  the  arch  of 
the  foot  and  in  the  inner  side  of  the  foot  be 
stretched,  torn,  or  divided.  This  can  be 
done  safely  by  means  of  tenotomy,  forcible 
stretching,  or  open  incision;  but  the  de- 
formity of  the  astragalus  still  remains.  In 
many  cases,  even  if  somewhat  resistant,  if 
the  deformity  is  rectified  and  the  foot  held 

a  sufficient  time  in  the  proper  position,  and  a  proper  walking  shoe  used 
for  a  year,  a  new  facet  of  the  astragalus  will  be  formed  and  a  cure  effect- 


Fig.  363.—  Sole  imprint  of  Same 
Foot  as  in  Fig.  360.  Three  Years  ;if- 
tPi-  Forcible  Correction. 


FIG.  364.— Congenital  Club-foot  in  a  Boy  Six      FIG.  365.— After  Forcible      Fig.  366.— Same  Case;  Walk- 
Years  Old.    (From  a  Photograph.)  Correction.  ing  Apparatus  Applied. 

ed.     In  a  few  cases  this  is  not  the  case,  and  in  such  instances  osteotomy 
of  the  neck  of  the  astragalus  suggests  itself  as  a  suitable  operation. 


40S 


ORTHOPEDIC    SURGERY 


The  procedure  will  not  be  found  a  difficult  one.      Tenotomy  or  open 
incision  aud  division  of  the  fascia  and  ligaments  should  be  doue,  aud  the 


Fig.  367.— Sole  Imprint  after  Removal  of  Astrag- 
alus for  Club-foot. 


Fig.  368.— From   Photograph   after  Removal   of 
Astragalus  of  Left  Foot  for  Club-foot. 


Fig.  369.— From  Photograph  after  Removal  of  Astragalus. 


CLUB-FOOT. 


-ID!) 


foot  stretched  and  manipulated  into  as  nearly  normal  a  position  as  possi- 
ble. An  incision  through  the  skin  is  made  from  the  tip  of  the  malleolus 
to  'the  inner  side  of  the  head  of  the  first 
metatarsal,  which  will  be  found  in  severe 
cases  close  to  the  malleolus.  The  incision 
is  close  to  and  nearly  parallel  to  the  tibialis 
anticus  tendon,  and  in  the  direction  of  the 
metatarsal.  The  incision  should  be  made 
to  the  bone,  and  the  foot  straightened,  as 
the  metacarpal  bone  is  separated  from  the 
malleolus.  The  scaphoid  will  be  seen  be- 
fore the  astragalus  is  encountered,  if  the 
deformity  is  great,  and  it  will  be  first 
within  the  reach  of  the  knife  in  all  cases. 
If  the  foot  is  still  further  stretched,  the 
scaphoid  begins  to  uncover  the  side  of  the 
astragalus,  and  the  neck  of  the  astragalus 
is  seen;  a  small  osteotome  is  entered  and 
placed  upon  the  neck  of  the  astragalus,  to 
the  proximal  side  of  the  scaphoid  articula- 
tion, and  the  neck  of  the  astragalus  divided 
or  nearly  divided.     The  foot  is  then  forcibly  ^     „„n    _  ,    T      .  .    .  _ 

J  J  Fig.  370.— Sole  Imprint  of  Case  of 

straightened,  and  the  neck  of  the  astraga-        ciub-foot  corrected  by  Tenotomy, 

i  ,  -      -n    j    ■      o        ,         j        ml  ,,    .  without  Contraction  but  with  Inver- 

lus  unchiselled  is  iractured.      Ihe  result  is       sion  of  the  Foot. 


Fig;  >  371.— Imprint   of  Left  Foot  before  Opera- 
tion. 


Fig.   372.— Imprint   of    Left   Foot    after   Opera- 
tion. 


410 


ORTHOPEDIC  SURGERY. 


similar  to  that  in  Macewen's  operation  for  knock-knee,  and  the  distortion 
at  the  neck  cf  the  astragalus  i3  removed.  It  i3  manifest  that  the  line  of 
section  cf  the  bone  at  the  neck  of  the  astragalus  should  be  transverse  to 


H°3. 


Fio  373.— Drawn  from  Casts  before  and  after  Excision.    2  and  4,  Before  excision  ;  i  and  3,  after 

excision. 


m>  374.— Imprint  of  Right  Foot  ( Congenital  Club-       Fig.  375.— Imprint  of  Right  Foot  after  Operation. 
foot)  before  Operation.  Osteotomy  of  neck  of  astragalus  and  os  calcis. 


CLUB-FOOT. 


the  axis  of  the  bone,  and  at  such  a  plane  that  when  the  equinus  deform- 
ity is  corrected  the  resulting  gap  at  the  section  should  not  be  greater 

than  necessary.  Strict  asepsis  is  essential. 
The  foot  should  bo  fixed  in  a  corrected  po- 
sition. A  wedge-shaped  resection  of  the 
neck  of  the  astragalus  through  a  skin  in- 
cision in  the  outer  and  upper  surface  of  the 
foot  has  been  performed,  but  linear  oste- 
otomy would  seem  to  be  preferable. 

Osteotomy  of  the  Head  of  the  Os  Calcis. 
— Tho  relation  of  the  cuboid  to  the  os 
calcis  is  frequently  masked,  lying  deeper 
than  that  of  the  scaphoid  and  astragalus, 
and  it  may  in  treatment  be  but  partially 
corrected.  The  distortion  of  the  os  calcis 
at  its  anterior  aspect,  if  not  corrected,  in- 
creases and  forms  an  obstacle  to  the  com-' 
plete  restoration  of  the  cuboid  to  the  normal 
position,  although  the  rest  of  the  deformity 
may  have  been  corrected. 

When  the  cuboid  is  cartilaginous  and 
the  ligaments  are  well  stretched,  the  de- 
fect at  the   anterior    portion    of    the    os 
calcis  can  be  overcome  by  forcibly  correcting  the  foot  and  retaining  it  in 


Fig.  376.— Imprint  after  Osteotomy  of 
Neck  of  Os  Calcis  and  Astragalus. 


FIG.  377.— From  Photograph  before  Opera- 
tion in  a  Boy  of  Twelve. 


Fig.  378. —Same  Case  after  the  Operation.    Osteotomy 
ot  neck  of  astragalus  and  os  calcis. 


the  corrected  position  by  means  of  a  plaster-of-Paris  bandage,  care  being 
taken,  however,  that  the  cuboid  be  restored  to  place,  and  in  time  it  will 


412 


ORTHOPEDIC    SURGERY 


be  found  that  the  cartilaginous  abnormality  in  the  shape  of  the  os  calcis 
is  gradually  changed  under  corrected  pressure. 

When  distortion  of  the  head  of  the  os  calcis  is  great,  no  amount  of 
mechanical  treatment  can  overcome  the  obstacle,  if  it  is  of  bone  and  if 
the  ligaments  are  strong,  binding  the  bones  in  a  distorted  position.  It 
is  manifest  under  these  circumstances  that  the  rational  treatment  is  a 
removal,  not  of  the  astragalus  or  cuboid,  but  of  a  part  of  the  projecting 
portion  of  the  head  of  the  os  calcis  (Figs.  371,  372,  374,  375). 

The  operation  is  not  a  new  one,  but  some  of  the  details  are  not  so 
generally  known  as  is  desirable.     After  complete  stretching  or  division 


Fig.  379.— From  Photograph  Two  Years  after  Tarsal  Resection. 


by  tenotomy,  force,  or  open  incision  of  the  contracted  tissues  on  the  inner 
and  under  side  of  the  foot,  tendons,  ligaments,  and  fasciae,  if  it  is  found 
that  the  front  of  the  foot  cannot  be  brought  to  a  perfectly  corrected  or 
over-corrected  position,  an  incision  should  be  made  on  the  outer  side  of 
the  foot,  passing  from  behind  the  external  malleolus  forward  and  down- 
ward. The  incision  should  be  a  curved  one,  and  the  chief  convexity 
should  be  at  the  forward  portion  of  the  os  calcis.  This  incision  should 
reach  to  the  bone,  and  should  expose  the  peroneal  tendons.  These  can 
either  be  drawn  to  the  side,  or  divided  to  be  stitched  later.  The  upper 
portion  of  the  incision  should  reach  behind  the  external  malleolus,  and 
should  extend  far  enough  up  to  allow  sufficient  retraction  of  the  flap  to 
give  room  for  the  osteotomy.     After  the  bone  has  been  reached,  the  peri- 


CIAjn-FOOT. 


413 


osteum  divided  and  pushed  aside,  an  osteotome  should  he  inserted  far 
enough  back  to  remove  a  sufficient  amount  of  bone.  The  direction  of 
the  insertion  of  the  osteotome 
should  be  such  as  to  allow  the 
placing  of  the  cuboid,  after  the 
bone  has  been  removed,  in  a  nor- 
mal position.  This  step  of  the 
operation  requires  some  nicety  and 
judgment,  as  it  is  of  importance 
that  the  front  plane  of  the  bone, 
after  the  wedge  has  been  removed, 
should  be  in  the  direction  of  the 
normal  facet  of  the  front  of  the 
os  calcis.  A  wedge-shaped  por- 
tion of  bone  should  be  removed 
from  the  anterior  and  outer  part 
of  the  os  calcis,  and  the  cartilagi- 
nous ends  saved  in  order  to  allow 
a  proper  amount  of  motion  be- 
tween the  cuboid  and  the  os  calcis 
after  recovery.  The  wedge- 
shaped  portion  of  bone  that  should 
be  removed  should  be  ample  and 
enough  to  allow  the  replacement 

of  the  front  of  the  foot  in   a  normal  or  over-corrected  position  and  the 
restoration  of  the  proper  direction  of  the  os  calcis. 

The  wound  should  be  carefully  washed  out  to  remove  any  fragments 
of  bone  that  may  have  been  left,  and  subsequently  stitched;   the  tendon 


Fig.  380.— Drawn  from  Photograph  after  Opera- 
tion. Double  osteotomy  of  neck  of  astragalus  and 
os  calcis. 


Fig.  381.— .A,  Diagram  of  Half-circle. 


FIG.  382— G,  Sole  Plate. 


of  the  peroneus  longus,  if  divided,  being  stitched.  The  foot  should  then 
be  dressed  with  proper  dressings  and  fixed  in  an  over-corrected  position 
by  plaster  bandages  according  to  the  ordinary  rules  in  osteotomy. 


4-14 


ORTHOPEDIC   SURGERY. 


Whether  this  operation  should  be  done  in  connection  with  an  oste- 
otomy of  the  neck  of  the  astragalus,  and  with  an  open  incision  at  the 
same  sitting,  is  a  matter  of  judgment  in  each  case. 

Imperfect  results  are  due  to  neglect  of  thorough  asepsis,  failure  to 


Fig.  383.— Lever  Correction  Apparatus  (Applied). 


W£ 


remove  a  sufficient  amount  of  bone,  failure  to  remove  it  in  such  a  direc- 
tion as  to  cure  the  deformity,  and  lack  of  care  in  placing  the  foot  in  a  cor- 
rected position  after  operation. 

Plaster  bandages  should  be  applied  from  the  toes  to  above  the  knee, 
which  is  slightly  flexed,  to  secure  the  bandage  from  twisting.  While  the 
plaster  is  hardening  the  cuboid  is 
pressed  upward  and  outward,  and 
the  front  of  the  foot  pressed  out- 
ward and  upward,  counter  press- 
ure being  applied  on  the  astraga- 
lus on  the  outer  and  upper  side, 
and  the  os  calcis  twisted  into  its 
normal  position. 

Treatment  can  be  carried  out 
with  a  plaster-of-Paris  bandage 
until  the  foot  is  thoroughly 
healed,  and  also  until  locomotion 
has  been  re-established. 

Walking  Appliances,  Retentive 
Appliances.  —  Whatever  method 
of  treatment  be  employed,  some 
form  of  appliance  will  be  needed 
after  correction  to  retain  the  tar- 
sal bones  in  proper  position  until 
the  muscles  and  ligaments  have 
adapted  themselves  to  the  normal 
position,  and  until  articular  facets 

have  been  formed  in  the  proper  direction,  or  the  astragalus  and  os  calcis 
have  assumed,  under  altered  pressure,  a  relatively  normal  shape.     It  is 


Fig.  384.— From  Photograph  after^  Removal  of  As- 
tragalus of  Left  Foot. 


CLUB-FOOT. 


415 


manifest  that  a  retention  appliauce  is  needed  for  a  shorter  time  after  os- 
teotomy is  correctly  performed  than  after  other  methods  of  correction. 


Fig.  385.— Congenital  Club-foot. 


Fig.  336.— The  3ame  Case  ;  Eesult  of  Treatment. 


The  corrected  foot  tends  to  relapse  in  two  directions— inversion  and 
elevation  of  the  heel.  If  this  is  unchecked  and  walking  is  done  in  im- 
proper attitudes,  hurtful  pressure  and  strain  fall  upon  the  bones  and  liga- 
ments of  the  foot,  and  relapse  takes  place.  This 
should  not  occur  if  proper  retention  and  walk- 
ing with  a  proper  attitude  of  the  foot  are  cared 
for. 

As   these   appliances   are  to  be  worn  a  long 
time,  they  should  be  light,  readily  adjusted  by 
the  nurse,  not  unsightly,  and  in  no  way  limit- 
ing  locomotion,  walking,  or  running.     The  best 
are  worn  within  the  shoe. 
The    length    of    time 
during  which   the  appli- 
ance is  needed  in   after- 
treatment   varies    and   is 
in  general  in   inverse 
proportion  to  the  size  of 
the  foot  or  the  difficulty 
of    correction,   infants  in 
arms    needing    a    reten- 
tion appliance  relatively 
longer  than  is  necessary  in  adult  cases,  in  which  if  correct  gait,  with  proper 
weight  bearing  upon  the  sole,  is  secured  for  a  few  months  relapses  are 
not  to  be  expected. 


Fig.  387.— The  Same  Case, 
with  Appliance  for  Correc- 
tion. 


Fig.  388.— Sole  of    Corrected 
Foot 


416 


ORTHOPEDIC   SURGERY. 


Tt  is  unnecessary  to  describe  all  the  various  retention  appliances  that 
have  been  used.     Mention  will  here  be  made  of  one  which  has  been  found 


Fig.  389. — Club-foot  Shoe,  from  Front  and  Back.    Arrows  show  direction  of  force  exerted  by  straps. 

of  service  in  the  writers'   experience,  after  a  careful  trial  of  the  usual 
varieties  of  appliances  designed  for  the  purpose. 


a 


c 


Fig.  390.— Details  of  Construction. 

It  is  to  be  remembered  that  a  retention  shoe  should  be  as  little  un- 
sightly and  cumbersome  as  possible,  should  allow  the  motion  of  the  foot 


CLUB-FOOT. 


417 


needed  in  correct  walking,  but  should  prevent  inversion  of  the  front  of 
the  foot  or  raising  of  the  heel  and  inner  edge  of  the  foot.  As  in  some 
instances  the  appliance  is  to  be  worn  for  some  time,  it  is  convenient  to 
have  it  worn  inside  of  the  shoe,  and  the  appliance  is  less  unsightly. 


Fig.  391.— Inner  and  Outer  Views. 

It  is  to  be  remembered  that  in  all  appliances  it  is  necessary  that  the 
pressure  preventing  a  faulty  position  of  the  foot  should  be  applied  pre- 
cisely, pressing  the  front  of  the  foot  and  tip  of  the  heel  outward,  the 


Fig.  392.— Taylor  Shoe  in  Process  of  Adjustment. 
The  solo  plate  applied  and  the  foot  strapped  to  the 
sole  plate. 


Fig.  393.— The  Upright  Brought  into  Place  and 
Acting  as  a  Lever,  Turning  the  Foot  to  the  Outer 
Side. 


front  of  the  foot,  especially  the  outer  edge  including  the  cuboid,  upward, 
and  the  back  of  the  foot,  i.e.,  the  end  of  the  os  calcis,  downward,  and  the 
outer  dorsum  of  the  foot  inward. 

Inward  pressure  should  be  exerted  upon  the  outer  edge  of  the  front  of 
the  os  calcis  and  astragalus,  and  not  upon  the  cuboid,  as  is  too  commonly 
done  in  inefficient  apparatus.     As  the  latter  bone  is  in  front  of  the  medio- 
27    . 


IIS 


ORTHOPEDIC    SURGERY. 


tarsal  joint,  inward  pressure  upon  it  not  only  fails  to  correct  the  de- 
formity but  tends  to  increase  it.  This  explains  the  occurrence  of  many 
relapses. 

The  apparatus  (Figs.  389-394),  which  is  a  modification  of  Taylor's 
varus  shoe,  consists  of  a  sole  plate  small  enough  to  fit  in  a  shoe  secured 

with  a  jointed  upright  furnished 
with  a  stop  to  prevent  the  plate 
from  dropping  into  the  equinus  po- 
sition. 

The  foot  is  secured  to  the  plate 
by  means  of  a  strap  which,  secured 
to  the  inner  side  of  the  plate,  passes 
from  the  inside  of  the  great  toe 
obliquely  to  the  outside  of  the  foot 
so  as  to  press  upon  the  anterior  outer 
surface  of  the  os  calcis  and  through 
a  loop  at  the  outside,  and  then  is 
brought  across  the  ankle  through  the 
metal  loop  and  secured  in  the  clasp. 
A  cross  strap  to  keep  the  toes  down, 
and  a  cross  ankle  strap  to  keep  the 
heel  down,  are  sometimes  necessary 
in  addition,  with  a  back  strap  behind 
the  heel. 

A  simple  form  of  retention  shoe 
can.  be  made  by  moulding  stiffened 
leather  over  a  cast  of  the  corrected 
foot  and  leg  and  stiffening  it  with 
steel  sole  plate  and  hinged  upright 
at  the  requisite  joints  to  prevent  the 
yielding  of  the  leather.  This  can 
be  laced  on  the  foot  and  cut  so  as 
to  allow  play  at  the  ankle. 
Either  of  these  appliances  can  be  worn  inside  of  a  shoe,  opened  like  a 
bicycle  shoe  well  down  to  the  toes. 

Relapses. — ~No  error  is  greater  than  a  common  one,  namely,  that 
tenotomy  alone  is  sufficient  to  correct  club-foot.  In  fact,  tenotomy  is 
only  the  beginning  of  a  course  of  treatment.  If  the  foot  is  rectified  and 
held  in  place  for  a  month,  it  is  supposed  by  some  surgeons  that  a  cure 
has  been  effected.     But  such  is  by  no  means  the  case. 

Moreover,  it  must  always  be  borne  in  mind  that  relapses  will  in- 
variably occur  unless  the  distortion  is  completely  corrected,  and  in  fact 
over-corrected.  In  club-foot  half-cures  are  no  cures,  and  little  reliance 
can  be  placed  on  the  curative  effect  of  time.     Efforts  at  correction  should 


Fig.  394.— Varus  Shoe.    (Children's  Hospital 
Report.) 


CLUB-FOOT. 


41!) 


be  continued  until  the  foot  can  be  easily  abducted  beyond  the  median 
line,  and  while  slightly  abducted,  can  be  flexed  so  that  the  dorsum  of  the 
foot  shall  form  less  than  a  right  angle  with  the  leg,  the  sole  of  the  foot 
being  flat,  there  being  no  twist  in  the  front  of  the  foot.  After  this  the 
correction  appliance  is  to  be  changed  for  a  retention  appliance. 

Kelapses  occur  in  a  certain  number  of  cases  simply  from  the  careless- 


FiG.  395. 


Fig.  396. 


Figs.  395  and  396.— Retention  Appliance  for  Club-foot,  Unapplied  and  Applied.    (Children's  Hospital 

Report.) 


ness  of  the  parents,  who  are  not  aware  of  the  necessity  of  retaining  the 
corrected  foot  in  the  proper  position  for  a  long  time.  The  foot  of  a 
healthy  infant  in  arms  is  often  held  in  an  equinus  position,  which  is 
often  overlooked  by  the  parent. 

In  cases  in  which  the  counteracting  muscles  are  congenitally  weaker 
than  they  should  be,  there  is,  of  course,  danger  that  the  gastrocnemius 
muscles  may  become  shortened  by  adaptive  shortening,  even  if  previ- 
ously of  sufficient  length,  as  happens  in  the  case  of  infantile  paralysis. 
When  the  foot  is  large  and  the  child  able  to  walk,  the  act  of  walking 


420 


ORTHOPEDIC    STRGERY. 


aids  correction  if  the  foot  is  prevented  from  twisting  and  the  weight  falls 
correctly  on  the  sole.  But  in  infants  in  arms  this  correcting  influence  is 
absent,  and  the  retention  appliance  needs  to  be  carefully  watched  until 
the  child  walks  and  walks  well.  Tn  cases  of  relapse  a  second  tenotomy 
is  advisable. 

Relapses   in   older  children   are   due   to  incomplete  correction,  either 
from  a  lack  of  thoroughness  or  from  the  existence  of  an  unusual  amount 

of  distortion  of  the  astragalus  or  os 
calcis  not  suspected,  and  demand- 
ing osteotomy,  or  from  too  early 
removal  of  the  fixation  appliance. 


r.-<  '-      .  -jiHtk 


FIG.  397. 


Fig.  398. 


Figs.  397  and  398.— Apparatus  Before  and  After  Application  of  the  Bandage.    CChildren's  Hospital 

Report.) 


In  some  instances  of  resistant  club-foot  it  is  found  impossible,  in  cor- 
recting the  foot,  completely  to  over-correct  the  equinus  deformity,  and  to 
enable  the  foot  to  be  brought  to  within  a  right  angle  with  the  leg.  If  this 
is  not  done,  inconvenience  is  felt  by  the  patient  in  taking  a  long  step,  and 
the  foot  is  turned  in  to  facilitate  this.  The  smaller  the  foot  the  greater 
this  danger.  If  this  is  not  corrected,  it  may,  in  some  instances,  seri- 
ously interfere  with  the  perfection  of  the  result. 

Relapses  in  infantile  club-foot  may  also  occur  from  the  neglect  of  a 


CLUB-FOOT. 


4^1 


fixation  shoe,  la  children  in  arms  the  feet  hang  according  to  gravity, 
unless  the  muscles  are  oi:  normal  activity.  The  muscles  in  club-foot, 
even  after  correction,  are  not  of  normal  activity;  and  the  feet  may  re- 
lapse and  deformity  reappear,  as  in  cases  of  paralytic  club-foot.  This 
may  also  result  if  the  children  do  not  walk  correctly  when  they  attempt 
to  walk. 

It  should  always  be  borne  in  mind  that  a  distortion  in  the  neck  of  the 
astragalus  or  in  the  head  of  the  os  calcis  exists,  even  in  infantile  club- 
foot, and  that  the  feet  are  not  permanently  corrected  until  the  alteration 
of  the  facets  into  a  normal  position  has  taken  place.     This  is  mdepend- 


Fig.  899.— Double  Congenital  Equino-varus. 


ent  of  bringing  the  foot  into  a  normal  position,  and  demands  fixation  in 
a  normal  position  for  some  time.  In  some  cases  this  is  more  needed 
than  in  others,  probably  because  the  alterations  of  the  facets  of  the 
astragalus  are  in  some  instances  alight. 

Imperfect  Results. — -The  obstacles  which  prevent  perfection  in  result 
are  as  follows :  Imperfectly  divided  tendons ;  imperfectly  divided  liga- 
ments and  plantar  fascia;  imperfectly  stretched  ligaments;  incorrect  re- 
lation between  the  scaphoid  and  anterior  facet  of  the  astragalus,  due 
either  to  anatomical  alteration  of  shape  of  the  astragalus  or  to  imperfect 
division  or  stretching  of  the  ligaments  which  bind  these  bones  together, 
in  the  correction  of  the  deformity;  similar  incorrect  relationship  between 
the  cuboid  and  os  calcis. 

Too  great  over-correction  of  the  deformity  and  the  development  of  a 
splay-foot  have  sometimes  resulted  from  over-zealous   treatment.     The 


422 


ORTHOPEDIC    SURGERY. 


danger  is,  however,  not  great;  and  instances  are  rare,  and  are  to  be  over- 
come by  the  treatment  for  a  valgus  foot. 

Inversion  of  the  foot,  after  cure  of  the  club-foot,  may  in  a  few  in- 
stances be  observed  from  imperfect  strength  of  the  outward  rotatory 
muscles  at  the  hip.  This,  however,  causes  but  little  disfigurement,  the 
inversion  usually  being  slight,  and  correcting  itself  by  the  normal  develop- 
ment of  the  muscles.  A  marked  toeing-in  of  the  foot  in  running  persists 
a  long  time  in  some  instances  in  which  the  foot  is  entirely  corrected  and 
the  walking  is  normal. 
It  disappears  with  the 
increase  of  muscular 
strength. 

A  relaxed  state  of 
■ttie  knee-joint  causing 
inversion  of  the  tibia  is 
not  uncommon  in  in- 
fant i  1  e    club-foot ;    it 

Fig.  ■101.— Side  View  at  Age  of  Twelve.    Left  foot  forward, 
showing  amount  of  motion  at  ankle.  < 


Fig.  400.— Condition  of  Feet  at  the 
Age  of  Twelve.    Front  view. 


Fig.  402.— Right  Foot  Forward. 


usually  corrects  itself  in  the  development  of  the  child  after  correction  of 
the  foot.  In  rare  instances,  however,  it  may  persist,  requiring  the 
longer  use  of  a  walking  appliance. 

There  appears  to  be  no  greater  liability  to  relapse  after  complete 
correction  by  mechanical  means  than  when  tenotomy  is  employed. 

The  accompanying  pictures  (Figs.  400,  401,  402)  are  taken  from  the 
photograph  of  the  feet  of  a  child  of  twelve  years  born  with  talipes  equino- 
varus  of  a  severe  type.  ISTo  cast  of  the  feet  at  the  time  of  infancy  was 
taken,  but  the  feet  resembled  those  in  the  preceding  cut  (Fig.  399). 
Treatment  was  begun  at  the  age  of  three  months,  and  was  entirely 
mechanical,  and  several  months  were  needed  for  correction,  bandages  and 
traction  being  chiefly  employed.  A  retention  appliance  was  worn  for  a 
year  and  no  subsequent  treatment  was  needed. 

Treatment  of  the  Muscles. — The  muscles  retarded  in  club-feet  by  dis- 
use need  development  before  a  complete  cure  is  effected.      Ordinarily  the 


CLUB-FOOT.  423 

muscles  develop  of  themselves  after  complete  correction,  if  the  limbs  are 
actively  used.  In  some  cases  the  development  is  slow  and  massage  and 
electricity  are  advisable. 

Generalization  as  to  Treatment. — The  literature  of  the  treatment  of 
club-foot  is  too  often  that  of  unvarying  success.  It  is  sometimes  as  bril- 
liant as  an  advertising  sheet,  and  yet  in  practice  there  is  no  lack  of  half- 
cured  or  relapsed  cases — sufficient  evidence  that  methods  of  cure  are  not 
universally  understood. 

Surgeons  differ  somewhat  in  regard  to  the  method  of  treatment  of 
club-foot,  but  the  following  statements  are  regarded  by  the  writers  as 
worthy  of  acceptance. 

First. — That  it  is  possible  to'  correct  completely  infantile  cases  of 
congenital  club-feet  without  the  help  of  any  operative  interference,  even 
tenotomy. 

Second. — Tenotomy,  however,  even  in  infants  is  of  assistance,  and  in 
older  cases  is  in  almost  all  instances  necessary  for  a  perfect  cure.  Tenot- 
omy properly  done  is  not  followed  by  any  unfavorable  results. 

Third. — Certain  resistant  cases  can  be  corrected  and  cured  without 
operation  upon  the  bone,  but  in  many  resistant  cases  considerable  force 
must  be  used. 

Fourth. — In  resistant  cases,  however,  when  there  is  deformity  of  the 
bone,  osteotomy  or  a  wedge-shaped  resection  of  the  astragalus  or  os  calcis 
is  necessary. 

Fifth. — Congenital  club-foot  is  a  thoroughly  curable  deformity,  pro- 
vided the  pathological  conditions  existing  are  thoroughly  understood,  and 
the  resisting  structures  overcome. 

Sixth. — For  cure  over-correction  of  the  deformity  is  necessary  and 
retention  in  an  over-corrected  position  until  the  normal  relation  of  the 
parts  has  been  established. 

Seventh. — The  best  retention  appliance  is  one  which  interferes  with 
the  normal  motion  the  least  without  permitting  the  distorted  position  of 
the  foot. 

Acquired  Club-Foot — Paralytic  Deformity. — The  most  common  form 
of  acquired  club-foot  is  that  following  infantile  paralysis  which  is  de- 
scribed in  another  chapter. 

The  prognosis  of  paralytic  club-foot  is  necessarily  more  unfavorable 
than  that  of  the  congenital  form,  although  the  distortion  is  more  readily 
corrected;  it  is  impossible  to  restore  the  affected  muscles  to  a  normal 
condition,  and  the  prolonged  use  of  some  form  of  appliance  is  generally 
necessar}^. 

In  some  instances,  however,  after  thorough  correction  and  retention 
for  a  while  in  a  corrected  position,  if  the  foot  is  of  sufficient  size,  relapse 
does  not  take  place,  or  only  in  a  partial  degree,  and  a  useful  and  but 
slightly  distorted  foot  remains. 


424  ORTHOPEDIC    SURGERY. 

The  treatment  of  paralytic  club-foot  is  to  be  conducted  on  the  same 
principles  as  that  of  the  congenital  type. 

Correction  is,  however,  much  less  difficult,  as  osseous  changes  are 
present  only  in  the  old  severe  and  neglected  cases. 

Operative  interference  is  often  unnecessary  if  thorough  mechanical 
treatment  is  applied  and  time  is  not  an  object. 

But  tenotomy  of  the  contracted  and  healthy  muscles  can  be  done  as  in 
congenital  cases,  though  over-correction  after  tenotomy  is  to  be  avoided. 
Immediate  correction  and  fixation  in  a  corrected  position  are  to  be  used 
after  tenotomy  as  in  the  congenital  form. 

The  walking  appliance  to  be  used  in  paralytic  cases  resembles  that 
which  has  been  described  in  congenital  cases. 

Club-Hand. 

Congenital  club-hand  is  a  rare  condition,  which  is  in  a  measure  anal- 
ogous to  congenital  club-foot.     It  is  usually  found  in  connection  with 


% 


Fig.  403.— Club-hand  with  Deficiency  of  Part  of  Radius. 

other  deformities.  The  name  is  applied  to  a  deviation  of  the  hand,  at 
the  wrist,  from  the  line  of  the  forearm;  and  this  deviation  is  almost 
always  in  the  direction  of  flexion. 

In  German,  the  distortion  is  known  as  Klumphand  and  in  French  as 
main  bote. 

The  modern  classification  of  the  distortion  is  to  speak  of  the  cases  as 
dorsal  and  palmar  club-hand,  as  the  deformity  is  toward  flexion  or  ex- 
tension ;    or  as  radial  and  ulnar,  or  cubital,  as  the  deviation  is  inward  or 


CLUB-HANI). 


425 


outward  at  the  wrist.  Mixed,  forms  are  the  most  common,  and  are 
spoken  of  as  radio-palmar,  etc  The  dorsal  forms  are  excessively  rare. 
The  bones  of  the  arm  may  be  normal,  but  more  commonly  they  are 
deformed,  or  the  radius  may  be  wanting  wholly  or  in  part.  The  carpus 
may  be  normal,  or  incompletely  developed,  or  almost  entirely  wanting.1 


FlG.  104. 


Figs.  404  and  405.— Club-hand. 


When  the  radius  is  deficient,  the  lower  end  of  the  ulna  is  enlarged  to 
articulate  with  the  carpus.  A  variety  of  anomalies  of  the  muscles,  ves- 
sels, and  nerves  may  occur. 

Etiology. — No  satisfactory  etiological  cause  can  be  assigned  for  the 
occurrence  of  club-hand,  beyond  the  usual  explanations  urged  to  account 
for. congenital  deformities  in  general. 

Symptoms. — In  looking  at  the  palmar  varieties  of  club-hand  it  is  seen 
that  the  Avrist  is  sharply  flexed,  and  that  perhaps  the  lower  end  of  the 


Fig.  406.— ClUb-hand. 


radius  may  be  covered  by  the  skin  and  traversed  by  the  extensor  tendons, 
while  the  carpus  articulates  with  the  under  surface  of  the  radius.  The 
forearm  is  wasted,   and  if  the  radius  is  absent  it  appears   to  be  very 


1  Bouvier:  "Diet.  Encycl.  des  Sc.  Med.,"  art.  Main. 


426  ORTHOPEDIC   SURGERY. 

slender  indeed.  The  hand  possesses  a  certain  degree  of  mobility  at  the 
wrist,  and  when  it  is  partly  replaced  the  flexor  tendons  can  be  felt  to  be 
rendered  tense,  and  stand  out  under  the  skin. 

The  diagnosis  is  evident,  and  any  pathological  process  which  is  ac- 
companied by  this  malposition  is  classified  as  club-hand. 

Treatment. — In  the  worst  cases,  in  which  there  is  much  bony  defi- 
ciency, the  choice  lies  between  amputation  and  doing  nothing.  The  former 
measure  is  not  generally  advisable,  because,  however  malformed  the  hand 
may  be,  the  patient  finds  a  way  to  make  the  deformed  hand  of  use,  even 
though  the  distortion  is  unsightly.  Osteotomy  of  the  bone  may  be  done 
if  it  is  curved.1 

In  milder  cases  tenotomy  of  the  resistant  muscles  or  stretching  the 
contraction  by  manipulation  or  apparatus  may  be  efficacious.  In  general 
the  decision  will  be  made  according  to  the  severity  of  the  case. 

If  treatment  is  begun  in  early  life,  it  is  generally  possible  to  correct 
the  deformity  by  bandaging  the  hand  to  splints,  or  by  the  application  of 
a  series  of  plaster-of -Paris  bandages. 

Tenotomy  is  not  advisable  if  milder  measures  are  likely  to  prove  suc- 
cessful, as  any  possible  impairment  of  the  movements  of  the  hand  is  to 
be  avoided,  and  tenotomy  of  the  extensors  and  flexors  of  the  fingers  has, 
in  a  few  instances,  led  to  loss  of  mobility  from  non-union  of  the  tendons. 

The  hand  may  be  immediately  rectified  after  tenotomy  or  left  in  its 
former  position  and  put  into  proper  place  only  after  several  days. 

With  proper  care,  the  results  of  treatment  are  generally  satisfactory 
in  cases  in  which  the  bony  malformation  is  not  excessive. 

1  R.  H.  Sayre:  Orth.  Trans.,  vol.  vi.,  p.  211  (with  bibliography)  ;  ibid.,  vol.  ix., 
p.  104. 


CHAPTER  XII. 

CONGENITAL    DISLOCATIONS. 

Frequency  and  occurrence.— Etiology. — Pathology. — Symptoms.  — Diagnosis.— Dif- 
ferential diagnosis. — Prognosis.— Treatment. — Congenital  dislocations  of  other 
joints  than  the  hip. 

Congenital  dislocations,  with  the  exception  of  dislocations  of  the 
hip,  occnr  so  rarely  that  they  are  of  interest  chiefly  as  surgical  curiosi- 
ties. The  very  great  preponderance  of  hip  dislocations  among  these  has 
never  been  satisfactorily  explained,  and  so  few  cases  of  congenital  dislo- 
cations of  other  joints  have  been  reported  that  the  etiology  of  the  affec- 
tion is  obscure,  except  for  the  light  afforded  by  the  study  and  analysis  of  • 
the  hip  dislocations.  There  is  one  point  of  difference  in  the  occurrence 
of  congenital  dislocation  of  the  hip  and  of  the  other  joints.  Dislocations 
of  the  hip  occur  most  often  in  otherwise  healthy  and  normally  formed 
children,  while  dislocations  of  the  other  joints  are  commonly  associated 
with  other  malformations,  such  as  acrania,  anencephalia,  spina  bifida, 
and  the  like. 

Congenital  dislocation  of  the  hip  is  neither  a  common  affection  nor 
one  of  very  great  rarity.  Among  7,900  cases  of  surgical  disease  in  chil- 
dren, applying  at  the  out-patient  department  of  the  Children's  Hospital, 
there  were  39  cases  of  congenital  dislocation  of  one  or  both  hips.  Chaus- 
sier, '  in  23, 293  infants  born  at  the  Maternite,  found  only  1  case  of  con- 
genital luxation.  But  it  is  probable  that  it  occurs  in  reality  much  oftener 
than  it  is  recognized  clinically.  Parise2  dissected  the  hip-joints  of  all 
children  dying  while  he  was  interne  at  the  Hopital  des  Enfants  trouves, 
and  in  332  he  found  congenital  dislocation  of  one  or  both  hips  in  3.3 

The  distribution  of  the  affection  between  the  sexes  and  in  one  or  both 
joints  can  be  seen  from  the  following  tabulation  of  collected  cases : 

Number.  Boys,  (lirls.  Rjg^1"8  Left  Double. 

Drachmann 77  10  (37  24  24  29 

Pravaz 107  1 1  96  27  29  51 

Kronlein.... 90  14  76  32  22  31 

N.  Y.  Orth.  Hosp.  and  Disp 25  2  23  5  p)           5 

Boston  Children's  Hospital 24  0  24  7  11  6 

Prahl  18  3  15  0  0  0 

341         40       301         95         96       122 

< ___ 

^haussier,  quoted  by  Kronlein:  Deutsch.  Chir.,  Lief.  26,  p.  83. 
"•  Parise:  Bull,  de  la  Soc.  de  Chir..  1866,  vol.  vii.,  p.  331. 
3Prahl:  Inaug.  Diss.,  Breslau  ;  abst.  Cent.  f.  Chir..  1881.  p.  57. 


42  8 


ORTHOPEDIC   SURGERY. 


Fig.  407.— Specimen  of  Double  Congenital  Dislocation  of  the  Hip  after  Removal  of  the  Soft  Parts.  A, 
Femur  not  operated  upon ;  7?.  operated  upon  with  improvement  in  position,  hut  still  not  in  normal 
position. 


COMJKNITAL    DISLOCATIONS. 


429 


The  affection  is  much  more  common  in  girls  than  in  hoys,  301  of 
these  341  cases  (88  per  cent)  having  been  observed  in  females.  No  etio- 
logical reason  worth  repeating  has  ever  been  advanced  to  account  for  this 
preponderance  in  girls  except  the  assertion  of  Dupuytreu,  that  females 
are  more  liable  to  malformation  than  males. 


r 


Fro.  408.— View  of  Innominate  Bone  and  Head  of  Femur  from  a  Case  of  Congenital  Dislocation  of  the 
Hip,  after  an  Operation  for  Formation  of  New  Acetabulum  and  Reduction. 


430 


ORTHOPEDIC   SURGERY. 


Etiol<m;y. 


The  affection  has  been  known  for  so  long  a  time  that  practically  num- 
berless theories  have  been  advanced  to  account  for  the  deformity. 

The  etiology  of  the  affection  is  not  known.  True  congenital  disloca- 
tion without  doubt  is  an  affection  of  uterine  life.  It  would  seem  also 
that  it  is  not  an  arrest  of  development  like  harelip,  but  like  congenital 

club-foot  rather  a  perversion 
of  it,  a  malposition  of  bones 
with  the  resulting  structural 
changes  of  the  soft  parts.  Vi- 
olence at  birth  alone  is  not 
considered  a  cause  of  true  con- 
genital dislocation.  The  the- 
ory that  the  deformity  is  due 
to  intra-uterine  pressure  at  a 
period  of  foetal  development  is 
held  by  many.1 

But  this  theory  does  not 
explain  the  fact  that  the  affec- 
tion is  much  more  frequent 
among  girls  than  among  boys. 
The  lack  of  complete  develop- 
ment in  the  acetabulum  de- 
scribed by  many  writers  will 
be  found  after  thorough  exam- 
ination of  pathological  speci- 
mens to  be  explained  by  the 
malposition  of  the  parts  during 
a  portion  of  the  period  of  f cetal 
life  rather  than  by  a  structural 
arrest  of  development.2 

There    is,    undoubtedly,    a 

tendency  to   heredity   in   con- 

Dupuytren3  relates  the  case  of  three  families  in 


Fig.  409. 


-Femur  in  Congenital  Dislocation,  Showing  Altera 
tion  in  Angle  of  Neck. 


genital  hip  dislocation. 


1  A  specimen  was  described  by  Mr.  Jackson  Clark  in  which  in  uterine  life  the 
thighs  were  flexed  for  so  long  a  period  without  extension  as  to  cause  firm  contrac- 
tion of  the  anterior  portion  of  the  capsule.  Later  extension  of  the  limb,  possibly 
from  an  increase  of  the  amniotic  fluid  or  from  any  cause,  would,  in  a  shallow 
acetabulum,  cause  dislocation  of  the  hip  (Brit.  Ortho.  Trans.,  vol.  i.). 

2  Path.  Soc.  Trans.,  vol.  xxxviii.,  308. 

3Dupuyten:  " Lecons  orales  de  Clin.  Chir.,"  Paris,  1832,  tome  iii.,  art.  viii. 


CONGENITAL   DISLOCATIONS.  4)5  L 

which  the   affection    was    present  iu    several    members,    and   cases    are 
related  by  Bouvier, '  Verneuil,2  Stadfeldt,  Caswell,  and  Volkmann. ' 

Pathology. 

The  changes  in  the  anatomical  structures  seen  in  congenital  disloca- 
tion are  found  in  the  capsule,  in  the  muscles,  and  in  the  bones.  The 
changes  in  the  capsule  are  such  as  would  naturally  follow  a  uterine  dis- 


WLm 

■ 

"JP^^rfS 

,jH 

Uti "  w'1*  '\&  i 

^_  ^^BHIBg 

'*:'% 

Fig.  410.—  Old  Congenital  Dislocation  of  Hip  with  Alteration  of  Neck  of  Femur  to  Shape  of  Acetabu- 
lum.   (Warren  Museum.) 

location  before  the  joint  structures  were  formed.  Normally,  the  capsule 
passes  from  the  rim  of  the  acetabulum  to  the  neck  of  the  femur,  the  head 
being  placed  well  in  the  socket.  In  congenital  dislocation,  when  the 
head  lies  out  of  the  socket  and  above  the  acetabulum,  the  capsule  is 
stretched.  Furthermore,  the  weight  of  the  body,  as  soon  as  the  individ- 
ual walks,  rests  not  on  the  head  of  the  femur  placed  under  the  acetabu- 
lum, but  falls  upon  the  capsule,  which  stretches  like  a  strap  from  the 
acetabulum  to  the  trochanter,  and  this  capsule  necessarily  becomes  thick- 

1  Bouvier:  "Le<j.  Clin,  sur  les  mal.  chron.  de  l'app.  locomoteur.'.' 

2 Verneuil:  Gaz.  des  Hop.,  1866,  68,  76. 

3  Volkmann  :  "  Krankkeiten  der  Bewegungsorgane  ;  "  Stimson  :  "Dislocations," 
Phila.,  1888,  p.  103;  Holmes-Coote,  Adams:  "Todd's  Encyc.,"  vol.  ii.  ;  Breschet: 
London  Med.  and  Surg.  Journal,  1835 ;  Journ.  Edin.  Phys.  Soc,  1855;  Bouvier: 
Arch.  Gen.  de  MM.,  Paris,  xiv.,  p.  439;  Bradford:  Orth.  Trans.,  vol.  xii. 


432 


ORTHOPEDIC    SURGERY. 


ened.  As  it  is  stretched  across  the  acetabulum  it  becomes  adherent  at 
the  rim  and  to  a  portion  of  the  ilium,  so  that  the  acetabulum  seems 
obliterated,  being  covered  by  thick,  strong,  fibrous  tissue,  reaching  from 


Lcnaq  apcis  neck. 


TYaTisveyse 


Fig.  411.— Twist  of  Neck  in  Congenitally  Dislocated  Femur,  Looking  from  Above  Downward. 

rim  to  rim.  This  portion  of  the  capsule  is  entirely  shut  off  by  adhesion 
from  that  which  surrounds  the  head  save  for  a  small  opening  at  the 
upper  portion  of  the  rim.     This  opening  may  be,  and  usually  is,  smaller 


Fig.  412.— Specimen  of  Congenital  Dislocation  of  Hip.    A,  Capsule  stretched  around  distorted  head ;  it, 
portion  of  contracted  capsule ;  C,  capsule  leading  to  acetabulum. 


than  the  head,  and  not  easily  stretched,  as  the  tissues  lose  their  elasticity 
from  the  fibrous  bands,  which  form  from  the  use  of  the  capsule  as  a 
weight-bearing  structure. 

The  muscles  are  changed  in  consequence  of  the  changed  position  of 
the  head.  Some  of  the  muscles  are  shortened,  others  are  lengthened. 
The  muscles  which  are  shortened  are  chiefly  the  adductor  group,  the 


CONGENITAL   DISLOCATIONS. 


\    ■>■  > 


psoas  and  iliacus,  and  the  muscles  reaching  from  the  tuberosity  of  the 
ischium  to  the  leg,  i.e.,  the  ham-string  muscles.  The  glutaei  muscles  are 
not  shortened,  and  the  group  of  muscles  which  pass  from  the  pelvis  to 
the   greater   trochanter,    the  obturators,    gemelli,    etc.,    are    lengthened. 


Fig.  413.— Double  Congenital  Dislocation  of  the  Hip.  Death  from  whooping-cough  three  months  after 
operation.  Left  hip  reduced ;  open  incision ;  right  relapsed  after  apparent  reduction ;  forcible  correc- 
tion ;  narrow  capsular  constriction. 


The  capsular  and  peri-articular  ligaments  adapt  themselves  to  the  position 
of  the  deformity,  and  those  which  are  attached  to  the  lesser  trochanter 
are  particularly  strong  and  firm  to  prevent  the  pushing  of  the  head  up- 
ward, when  weight  falls  upon  the  leg.  It  is  these  tissues  which  op- 
pose any  attempt  at  reduction,  and  unless  they  are  stretched  or  divided 
the  deformity  cannot  be  corrected.  The  alteration  in  the  bone  consists 
28 


4:34  ORTHOPEDIC   SURGERY. 

of  a  flattening  or  alteration  of  the  shape  of  the  head,  a  twist  of  the  neck, 
the  consequence  of  malposition  of  the  head,  and  in  the  shape  of  the 
acetabulum,  which  is  sometimes  triangular  in  shape  and  shallow. 

There  are  three  varieties  of  congenital  dislocation,  classified  accord- 
ing to  the  position  of  the  head.  They  may  be  classed  as  backward,  up- 
ward, and  forward.  In  the  backward  variety  the  head  lies  upon  the 
dorsum  of  the  ilium,  resembling  the  position  of  the  usual  traumatic  dis- 
location. In  the  upward  dislocation  the  head  rests  above  the  acetabu- 
lum, and  in  the  forward  the  head  lies  close  to  the  anterior  spine. 

If  the  point  of  suspension  is  directly  over  the  proper  place  for  the 
acetabulum,  the  patient's  pelvis  is  hung  in  a  comparatively  normal  plane, 
but  if  much  behind  it  the  pelvis  is  tilted  and  severe  lordosis  results,  the 
latter  being  the  more  common  condition. ' 

Hung  in  this  way,  the  pelvis  develops  abnormally,  the  crests  of  the 
ilia  approach  each  other,  the  tuberosities  of  the  ischia  become  farther 
apart,  the  whole  centre  of  the  bone  is  carried  upward  and  backward,  and 
the  lateral  surfaces  thus  tend  to  become  vertical. 

Symptoms. 

The  deformity  usually  attracts  no  attention  until  the  child  learns  to 
walk  at  the  age  of  two  or  even  three  years.  Then  it  is  noticed  to  stand 
ordinarily  with  its  back  very  much  arched  and  to  waddle  most  markedly 
when  walking  is  well  begun.  This  waddle  is  characteristic  and  very 
marked.  When  the  dislocation  is  only  unilateral,  the  waddle  becomes 
an  exaggerated  limp ;  in  stepping  on  that  leg  the  child  suddenly  lurches 
violently  to  the  affected  side,  and  the  leg  seems  to  have  grown  suddenly 
shorter,  the  child  recovers  itself  at  once  and  goes  on  with  this  sudden 
giving  way  whenever  the  affected  leg  is  stepped  upon.  In  double  dis- 
location, in  young  children,  the  prominence  of  the  trochanters  is  not 
marked  enough  to  attract  attention ;  in  older  persons,  however,  the  promi- 
nence of  the  trochanters  and  buttocks  is  most  noticeable.  There  is  no 
complaint  of  pain  as  a  rule,  although  people  with  such  deformities  are 
particularly  subject  to  sprains  and  wrenches  of  their  imperfect  joints. 
They  tire  more  easily  than  other  children,  although  often  their  endurance 
is  wonderful  when  one  considers  how  serious  is  their  mechanical  disa- 
bility. 

Diagnosis. 

The  diagnosis  rests  chiefly  on  one  point,  the  position  of  the  trochan- 
ters above  Nelaton's  line,  which  is  drawn  from  the  anterior  superior  spine 

1  Holmes-Coote  :  Lancet,  1800 ;  N.  Y.  Journ.  of  Med.,  1848  ;  Carnochan,  Berend  : 
Brit.  Med.  Journ.,  1861;  Canton:  London  Med.  Gaz.,  xli.  ;  Birnbaum  :  Wien.  med. 
Presse.  1859;  Bouvier:  Bull,  de  l'Acad.  de  Med.,  183,  189. 


CONGENITAL    DISLOCATIONS. 


43;' 


of  the  ilium  to  the  tuberosity  of  the  ischium.  In  small  children  it  is 
often  a  difficult  point  to  determine  whether  the  trochanter  is  on  the  line 
or  very  slightly  above  it.  The  displacement  of  the  trochanter  upward 
varies  from  half  an  inch  to  one  or  two  inches,  according  to  the  severity 
of  the  case. 

As  the  child  lies  on  its  back,  the  perineum  is  noticed  to  be  unusually 
broad,  the  legs  will  perhaps  be  everted,  perhaps  in  normal  position,  and 


Fig.  414.—  Double  Congenital  Dislocation  of  the  Hip, 
(Fiske  Prize  Fund  Essay.) 


Fig.  415.—  Lordosis  and  Prominence  of  Tro- 
chanters in  Congenital  Dislocation  of  the  Hip. 
(J.  S.  Stone.) 


on  manipulating  them  they  will  be  found  to  be  unusually  movable,  espe- 
cially in  the  direction  of  eversion.  A  click  more  or  less  marked  will 
ordinarily  be  felt  as  the  head  of  the  bone  glides  over  a  band  of  fascia  or 
the  rudimentary  acetabulum,  but  a  similar  click  is  sometimes  felt  in 
children  with  normal  hip-joints. 

On  pulling  the  leg  with  gentle  force  the  trochanter  will  be  felt  to 


436 


ORTHOPEDIC    SURGERY. 


come  down,  if  the  other  hand  is  placed  upon  it,  and  to  slip  back  when 
the  leg  is  released,  and  a  measurement  will  show  that  the  leg  has  actually 
been  lengthened  temporarily.  This  movement  is  most  marked  when  the 
thigh  is  flexed  and  traction  is  made  at  a  right  angle  to  the  axis  of  the 
body. 

The  muscles  are  in  good  condition  and  the  children  ordinarily  very 
healthy  ones.      In  unilateral  dislocation,  the  leg  of  the  affected  side  is 

slightly  smaller  than  the  other. 

The  diagnosis  must  not  be  made 
on  the  simple  shortening  of  one 
leg.     That  is  so  common  an  occur- 


FiG.  416.— Unilateral  Dislocation  of  the  Hip. 
(Fiske  Prize  Fund  Essay.) 


Fig.  417.— Prominence  of  Trochanters  in  Double 
Congenital  Dislocation  of  the  Hip.  (Fiske  Prize 
Fund  Essay.) 


rence  in  children  otherwise  normal  that  it  is  of  slight  importance  unless 
there  is  the  additional  sign  of  a  trochanter  above  Nelaton's  line. 

In  larger  children  and  adults,  the  conformation  and  outline  of  the 
hips  are  so  distinctive  that  the  diagnosis  may  be  made  almost  at  a  glance; 
but  in  young  children  this  is  not  the  case. 

Trendelenburg  has  called  attention  to  an  important  diagnostic  symp- 
tom. When  a  normal  child  stands  upon  either  limb  and  flexes  the  other 
at  the  knee  and  thigh,  the  line  of  the  fold  of  the  buttock  will  be  seen  to  be 


( !0N<  I  ENITAL   DISLOCATIONS. 


437 


kept  on  a  level.      In  the  case  of  congenital  dislocation  of  the  hip,  how- 
ever, the  opposite  buttock  and  that  of  the  limb  on  which  the  patient 
stands  will  be  seen  to  drop  if  the  patient  takes  this  attitude.     Tins  is  to 
be  explained  by  the  fact  that  in  congenital  dislocation  of  the  hip,  own 
to  the  fact  that  the  head  of  the  femur  is  not  in  the  socket,  the  muscles 


Fig.  418.— Lordosis  in  Double  Congenital  Disloca- 
tion of  the  Hip.    (Fiske  Prize  Fund  Essay.) 


Fig.  419.— Broadening  of  Perineum  in  Double 
Congenital  Dislocation  of  the  Hip.  (Fiske  Prize 
Fund  Essay.) 


from  the  great  trochanter  and  the  pelvis  (which  serve  to  keep  the  pelvis 
when  supported  on  one  side  level)  have  no  purchase  and  are  therefore 
inefficient. 

Differential    Diagnosis. 

The  following  affections  may  be  confounded  with  congenital  disloca- 
tion of  the  hip  in  smaller  children :  coxa  vara,  distortion  following  infan- 
tile paralysis,  separation  of  the  epiphysis,  deformity  following  early 
arthritis  of  infancy,  traumatic  dislocations,   and  the  deformities  of  hip 

disease. 

In  all  these  affections,  with  the  exception  of  the  first,  viz.,  coxa  vara, 


4:38  ORTHOPEDIC    SURGERY. 

there  should  be  a,  history  of  previous  injury  or  illness;  and  in  all,  with 
the  exception  of  coxa  vara  and  infantile  paralysis,  the  freedom  of  motiou 
of  the  femur  seen  in  early  congenital  dislocation  is  not  found. 

Coxa  vara,  or  the  rhachitic  distortion  of  the  neck  of  the  femur,  which 
shortens  the  limb  and  raises  the  trochanter  above  Nelaton's  line,  may  be 
confounded  with  congenital  dislocation. 

The  mistake  can  be  avoided  if  the  fact  is  borne  in  mind  that  in  coxa 
vara  the  head  is  in  its  normal  socket,  while  in  congenital  dislocation  the 
head  is  to  be  felt  outside  of  the  acetabulum. 

Coxa  vara  is  rarely  seen  before  five  years  of  age,  and  is  only  very 
exceptionally  noticed  as  early  as  three. 

In  small  children  with  fat  buttocks  it  is  sometimes  difficult  to  find 
with  certainty  the  dislocated  head.  The  diagnosis  is  aided  by  remem- 
bering that  when  the  head  of  the  femur  is  in  the  acetabulum,  rotation 
takes  place  with  the  acetabulum  as  the  centre,  and  the  neck  as  the  radius 
of  the  arc  of  motion ;  when  the  head  is  out  of  the  acetabulum,  the  tro- 
chanter is  the  centre  of  motion,  and  the  looser  head  describes  the  arc. 

The  affection  of  congenital  dislocation  is  occasionally  regarded  as  a 
disease  of  the  spine,  as  marked  lordosis  is  always  present,  and  in  many 
instances  spinal  corsets  have  been  applied  with  the  idea  that  this  is  the 
chief  source  of  the  trouble. 

A  skiagraphic  picture  is  of  great  value  in  diagnosis,  and  if  accurate 
is  conclusive.  In  young  children,  owing  to  the  large  amount  of  cartilage 
in  the  epiphysis  (translucent  to  an  cr-ray),  radiographs  are  not  always  so 
definite  as  is  desirable. 

Prognosis. 

The  disability  caused  by  this  affection  in  childhood  is  slight.  The 
limp  is  noticeable,  and,  in  double  congenital  dislocation,  may  be  distress- 
ing. As  the  patient  becomes  older  and  the  weight  increases,  some  an- 
noyance may  be  caused  in  adolescence ;  but  the  disability  ordinarily  is 
not  great  until  middle  life  or  old  age.  In  single  dislocation  the  disability 
in  adults  may  be  only  a  disability  to  engage  in  active  occupation,  accom- 
panied by  occasional  attacks  of  severe  muscular  pain,  with  muscular 
cramps.  These  attacks  subside  under  rest,  but  if  the  patient  becomes 
heavier  or  feeble,  they  may  necessitate  the  use  of  crutches  and  cause 
severe  disability.  When  the  dislocation  is  on  the  dorsum  the  disability 
is  greater  than  when  it  is  anterior  or  above  the  acetabulum.  Muscular 
patients  suffer  less  than  those  with  feeble  muscles.  In  double  dislocation 
the  disability  is  increased. 

No  new  acetabulum  of  any  practical  importance  forms  in  most  of  the 
cases,  and  with  the  body  suspended  from  the  femurs  by  a  loose  capsular 
ligament,  the  patient  goes  through  life  walking  with  the  greatest  discom- 


CONGENITAL   DISLOCATIONS.  4:39 

fort  and  effort  at  each  step,  always  preserving  that  most  characteristic 
swaying  from  side  to  side. 

If  so  uncertain  a  matter  can  be  formulated,  it  may  be  said  that  in 
general  the  tendency  of  these  cases  when  untreated  is  to  remain  stationary 
or  to  grow  somewhat  worse.  The  pelvis,  although  altered  in  shape,  does 
not  appear  to  be  changed  in  such  a  way  as  to  interfere  with  childbirth. 

The  prognosis  in  cases  which  are  treated  will  be  considered  under 
that  head. 

Treatment. 

Treatment  by  Extension  and  Apparatus. — When    one    considers    the - 
problem  to  be  solved  in  the  treatment  of  congenital  dislocation  of  the  hip, 
it  is  easy  to  see  why  the  remedial  means  proposed  are,  in  general,  so  in- 
efficient. 

The  methods  for  treatment  of  congenital  dislocation  of  the  hip  are: 
(1)  by  apparatus;  (2)  by  operative  reduction;  (3)  by  forcible  reduction 
without  incision. 

The  treatment  by  apparatus,  consisting  of  the  application  of  corsets 
pressing  upon  the  trochanters  to  check  the  increase  of  the  sinking  of  the 
pelvis  between  the  hips  and  the  lordosis,  is  certainly  palliative  rather 
than  curative.  The  same  may  be  said  of  treatment  by  traction  appliances 
and  ischiatic  supports. 

The  treatment  by  traction  recommended  by  Guerin,  Pravaz,  Carno- 
chan,  and  more  recently  in  a  much  more  complete  form  by  Buckminster 
Brown,  cannot  be  regarded  as  reliable  or  generally  practicable,  as  re- 
lapses eventually  occur  after  apparent  cure.1 

The  methods  of  treatment  by  operation  which  have  been  suggested 
are  numerous;  that  of  reduction  after  subcutaneous  tenotomy  of  the 
muscles,  from  the  evidence  shown  by  dissection  and  pathological  speci- 
mens, is  manifestly  inadequate  if  the  object  is  to  obtain  a  complete  reduc- 
tion of  the  dislocated  hip. 

Treatment  by  excision  practised  by  Rose,  Huesner,  and  Margary 
hardly  recommends  itself  as  justifiable,  unless  in  painful  or  helpless  cases 
of  single  dislocation ;  but  in  double  congenital  dislocation  it  would  seem 
of  doubtful  advantage. 

Operative  Reduction. — To  Hoffa  belongs  the  credit  of  having  first  pre- 
sented to  the  profession  an  operative  method  of  value.  This  has  been 
modified  by  Lorenz  and  himself  and  may  be  described  as  follows : 

The  patient  is  to  be  placed  upon  the  back  with  the  limb  slightly 
abducted  and  rotated  outward.  The  incision  is  made  in  a  line  drawn 
from  in  front  of  the  anterior  superior  spine,  obliquely  downward  and  back- 


1  Bull,  de  TAcad.  de  Med.,  Paris,  vol.  iii.,  p.  408;  Bull,   de  la  Soc.  de  Chir., 
1864,  218;  Boston  Med.  and  Surg.  Jour.,  June  4th.  1885. 


440 


ORTHOPEDIC    SURGERY 


Fig.  420.— Congenital  Dislocation  lteiluc 


CONGENITAL  DISLOCATIONS.  4+1 

ward,  crossing  the  femur  a  short  distance  below  the  top  of  the  trochanter. 
The  incision  should  be  along  the  outer  edge  of  the  tensor  vaginae  femoris, 
between  this  and  the  anterior  border  of  the  glutseus  inedius.  The  inci- 
sion should  pass  well,  below  the  top  of  the  femur,  and  should  cross  it 
slightly  above  the  level  of  the  trochanter  minor.  The  tensor  vaginae 
femoris  is  retracted  and  the  fascia  lata  divided  by  a  straight  incision, 
and,  if  necessary,  by  an  additional  cross  incision.  The  glutaeus  is  also 
retracted,  and  beneath  the  tensor  muscle  the  rectus  femoris  will  be  found, 
with  a  reflected  tendon  passing  outward,  to  be  attached  to  the  ilium  above 
the  acetabulum.  If  the  muscular  tissues  are  well  retracted  the  capsule 
will  be  uncovered  and  can  be  split.  This  should  be  done  by  an  incision 
in  the  direction  of  the  original  skin  incision,  and  should  be  free  enough 
to  expose  the  whole  head  and  neck  as  far  as  the  trochanteric  line,  and, 
if  necessary,  a  cross  incision  is  made.  An  assistant  should  flex  the  thigh 
to  a  right  angle  to  the  trunk,  and  the  attachments  of  the  capsule  to  the 
neck  and  the  trochanteric  line,  including  the  lesser  trochanter,  should  be 
thoroughly  freed  both  on  the  anterior  and  posterior  surface  of  the  neck  to 
such  an  extent  that  the  surgeon  can  pass  his  finger  completely  around  the 
neck.  The  head  can  then  be  thrown  out,  the  ligamentum  teres  having 
been  divided,  if  present.  The  head  of  the  femur  can  be  then  pulled 
aside  and  a  clear  view  of  the  capsule  covering  the  acetabulum,  as  well  as 
the  acetabulum,  can  be  had.  If  the  capsule  is  constricted  above  the 
acetabulum  it  can  be  cut  with  a  herniotome  or  stretched  with  a  dilator, 
or  enlarged  with  a  curette.  It  is  important  that  the  bony  edge  over- 
hanging the  acetabulum  should  project  sufficiently  to  furnish  a  firm 
socket  after  the  head  is  reduced.  It  is  sometimes  difficult,  if  the  tissues 
are  imperfectly  divided,  to  find  the  socket  for  the  reason  that  a  portion 
of  the  capsule  lies  flat  across  the  socket  and  is  adherent  to  the  edges,  the 
surgeon  feeling  only  the  upper  edge  and  a  mass  of  connective  tissue;  but 
when  this  difficulty  is  met  it  is  necessary  to  enlarge  the  incision,  as  it  is 
essential  that  the  head  be  placed  well  in  the  socket.  A  curette  to  enlarge 
the  acetabulum  may  be  needed. 

It  is  sometimes  necessary,  if  the  head  of  the  femur  is  conical  in 
shape,  to  remove  a  portion ;  but  if  the  cartilage  on  the  acetabulum  is  re- 
moved and  the  head  of  the  femur  freed  from  its  cartilage,  ankylosis  is 
liable  to  result.  It  is  particularly  necessary  that  the  capsule  should  not 
be  folded  in  attempted  reduction  in  such  a  way  as  to  prevent  the  free 
entrance  of  the  head  into  the  acetabulum,  and  it  is  especially  important 
that  the  connection  between  the  acetabulum  and  the  femur  at  the  trochan- 
teric line  and  lesser  trochanter  should  not  be  so  firm  as  to  prevent  the 
easy  reduction  of  the  head  into  the  socket.  When  it  is  found  that  the 
head  when  reduced  into  the  socket  will  not  remain  there  if  the  leg  is  ad- 
ducted  or  extended,  some  remaining  fibres  of  the  capsular  attachments  on 
the  anterior  surface,  passing  from  the  ilium  to  the  lesser  trochanter  and 


442 


ORTHOPEDIC    SURGERY. 


its  adjacent  parts,  will  be  found  to  exist.  After  the  acetabulum  has  been 
deepened  sufficiently,  the  reduction  of  the  dislocation  should  be  per- 
formed. 

After  the  reduction  the  redundant  capsule  can  be  stitched,  with  free 
drainage,  or  packed,  according  to  the  judgment  of  the  surgeon  as  to  need 


Fig.  421.— Line  of  In 
vision  for  Operative  Ke 
duction. 


Fig.  422.— Second  Step.    Fig.  423.— Third  Step. 


Fig.  424.— Fourth  Step. 


of  complete  drainage,  or  as  to  trust  in  healing  and  absorption.  Drainage 
is  of  especial  importance,  as  the  cavity  is  a  deep  one  and  may  be  shut  off 
in  the  process  of  repair  by  muscular  contraction.  Furthermore,  in  this 
region  the   danger   of  infection  from  urine,   in  some  small  children,   is 


Fig.  425. — Diagram  of  Section  of  Capsule  iu  Normal  and  in  Congenitally  Dislocated  Hip. 

great.  The  cases  of  death  from  sepsis  are  apparently  due  to  omission  of 
this  precaution.  The  limb  should  be  flexed  by  means  of  a  plaster-of- 
Paris  spica  reaching  from  the  thorax  down  to  the  foot,  holding  the  limb 
in  a  strongly  abducted  position.  The  position  of  the  limb  can  be  gradu- 
ally brought  to  normal  by  later  application  of  plaster- of -Par  is  bandages. 

Forcible  Reposition. — This  method,  presented  by  Paci  and  greatly  im- 
proved by  Lorenz,  has  been  employed  with  undoubted  and  permanent 
success  and  with  much  less  risk  than  that  following  reduction  by  incision. 


CONGENITAL   DISLOCATIONS. 


443 


The  operation  is  applicable  in  children  younger  than  five  and  in  some 
cases  in  children  as  old  as  seven.  Lorenz  has  reported  success  in  even 
older  children. 

Before  the  operation,  as  a  preparatory  measure,  traction  to  stretch  the 
muscles  can  be  employed,  combined  with  gradually  increasing  abduction. 


Fig.  427. 


Fig.  426. 

FIGS.  426  and  427.— Diagram  Showing  Difficulties  in  Reduction.    1,  In  the  capsule  covering  the  acetabu- 
lum ;  2,  in  the  shortened  capsule  between  the  acetabular  rim  and  the  lesser  trochanter. 

After  a  short  time  of  this  preliminary  treatment  the  patient  should  be 
anaesthetized  and  extreme  force  applied  to  the  limb,  with  the  thigh  ab- 


FIG.  428. 


Fig.  429. 


JIGS.  428  and  429.— Diagram  Showing  Pelvi-trochanteric  and  Pelvic  Muscles  in  Congenital  Dislocation  of 

Hip. 

ducted.  Traction  is  exerted  by  means  of  a  loop  of  yarn  placed  around 
the  ankle  and  attached  to  a  screw  force  fastened  to  the  end  of  the  table. 
Counter-traction  is  exerted  by  means  of  a  long  sheet  placed  beneath  the 


444 


OKTHOPEDIC    SURGERY 


perineum  on  the  unaffected  side  or  by  means  of  perineal  resistance. 
Force  is  slowly  applied  and  as  the  pelvis  tilts  abduction  is  developed. 
This  stretches  the  adductors,  the  flexors,  the  hamstrings,  the  rectus 
femoris,   and  the  capsule,   the  shortened  condition  of  which  holds  the 


Fig.  430.— Apparatus  fur  Traction  in  Abducted  Position. 


femur  in  place.  After  this  procedure  has  been  carried  on  for  several 
minutes,  accompanied  by  forcible  manual  stretching,  by  massage  of  the 
adductor  group,  aided  possibly  by  a  tenotomy,  the  different  manoeuvres 
to  stretch  pericapsular  ligaments  of  the  hip  should  be  executed.  The 
reduction  takes  place  with  a  noticeable  jerk  as  the  head  of  the  femur 


"7 


Fig.  431.— Double  Congenital  Dislocation  Unreduced. 


passes  into  the  acetabulum.  If  dislocation  recurs  when  the  leg  is  ad- 
ducted  and  extended  it  indicates  that  the  anterior  and  inner  attachments 
of  the  muscles,  ligaments,  and  capsule  are  not  stretched,  redislocation 
takes  place  if  the  limb  is  brought  to  a  straight  position  from  an  abducted 
one,  and  further  stretching  is  necessary.     After  the  reduction  is  thor- 


CONGENITAL   DISLOCATIONS. 


445 


oughly  assured  the  limb  should  be  placed  in  a  plaster-of-Paris  spica  in  a 
strongly  abducted  position. 

It  will  be  found  that  the  chief  obstacle  to  reduction  is  in  the  contrac- 
tion on  the  inner  side  of  the  joint,  especially  in  the  adductors  and  the  peri- 
capsular  ligaments  which  connect  the  upper  part  of  the  acetabulum  with 


Fig.  432.— Congenital  Dislocation.    Reduction  by  incision.    Osteotomy  of  shaft  to  correct  twist  of  neck. 


the  lesser  trochanter.  It  is  therefore  necessary  that  the  limb  should  be 
put  up  in  an  abducted  position  and  kept  in  this  position  until  healing  has 
been  secured. 

When  a  twist  in  the  neck  of  the  femur  has  been  developed  by  its 
abnormal  position  from  the  congenital  malposition,  the  limb  may  need  to 
be  inverted  after  reduction  in  order  to  maintain  during  healing  the  proper 
relation  of  the  head  to  the  acetabulum.  When  this  twist  of  the  neck  is 
marked,  a  subsequent  linear  osteotomy  of  the  shaft  of  the  femur  and 
correction  of  the  twist  are  necessary  to  establish  the  proper  position  of  the 
corrected  limb  in  walking. 

The  after-treatment  needs  to  be  conducted  with  care  to  prevent  re- 


446  ORTHOPEDIC    SURGERY. 

lapse.  This  is  liable  to  occur  if  the  head  of  the  femur  has  not  been  thor- 
oughly placed  under  the  acetabulum,  if  the  acetabulum  has  not  a  suffi- 
ciently projecting  upper  edge  and  has  not  been  sufficiently  deepened,  or  if 
the  redundant  portion  of  the  capsule  has  been  folded  in  during  the  re- 
duction between  the  head  and  the  acetabulum,  or,  if  a  marked  twist  of 
the  neck  exists,  a  relapse  may  take  place  in  locomotion  unless  the  twist 
is  corrected  by  growth  or  operation. 

The  most  efficient  method  of  after-treatment  consists  of  fixation  of 
the  limb  in  a  position  in  which  relapse  is  impossible  until  the  ligaments 
and'  muscles  have  adapted  themselves  so  as  to  retain  the  head  in  the  cor- 
rected position.  This  position  is  one  of  strong  abduction  which  is  gradu- 
ally brought  to  the  normal  position.  Walking  on  the  limb  so  far  as  it  is 
practicable  is  permissible  with  the  limb  in  an  abducted  position,  and  the 
later  plaster-of-Paris  bandages  need  not  include  the  foot. 

When  redislocation  occurs  walking  will  be  improved  provided  the 
posterior  dislocation  can  be  made  into  an  anterior  one. 

The  after-treatment  necessarily  involves  time,  six  months'  fixation 
being  usually  necessary. 

The  question  of  absolute  ultimate  benefit  from  the  operation  is  not 
easily  determined,  as  the  final  result  is  somewhat  dependent  upon  the 
child's  growth.  As  a  rule,  some  time  is  needed  before  the  improvement 
in  the  child's  gait  after  operation  is  marked. 

Generally,  children  and  adolescents  suffer  little  from  the  deformity  if 
single,  but  the  annoyances  that  follow  in  old  age  justify  thorough  meas- 
ures of  correction  in  youth. 

It  is  manifest  that  when  the  reduction  of  the  head  is  secured  it  is  bet- 
ter for  the  usefulness  of  the  limb  and  the  growth  of  the  trunk  than  when 
dislocation  remains. 

Congenital,  Dislocations  of  Other  Joints  than  the  Hip. 

It  will  be  necessary  to  mention  only  the  most  frequent  varieties  of 
congenital  dislocations  of  other  joints  than  the  hip. 

Shoulder- Joint. — These  dislocations  may  be  divided  into  two  classes: 
those  in  which  the  glenoid  cavity  is  absent  or  imperfectly  developed,  and 
those  in  which  it  is  approximately  normal.  In  the  latter  class  the  posi- 
tion of  the  head  of  the  humerus  is  usually  subspinous.  Shoulder- joint 
dislocations  of  this  class  present  three  distinct  forms:  (1)  those  due  to  ir- 
regular development  of  the  joint;  (2)  those  in  which  the  bones  are  nor- 
mally formed  and  in  which  the  displacement  may  have  occurred  during 
delivery;  and  (3)  those  also  with  normal  bones  in  which  the  displace- 
ment is  the  result  of  paralysis  antedating  birth,  or  caused  during 
delivery. 

Dislocations  of  the  Shoulder  Apparently  Congenital. — The   lesion   is 


CONGENITAL   DISLOCATIONS.  447 

sometimes  double  or  associated  with  other  congenital  affections,  and  in 
one  case  two  children  in  one  family  were  similarly  affected. 

In  a  case  of  the  first  class  described  by  Smith  there  was  hardly  a  trace 
of  the  normal  glenoid  cavity. 

In  the  class  of  cases  in  which  the  glenoid  cavity  is  approximately  nor- 
mal the  origin  is,  of  course,  less  certainly  congenital.  The  position  of 
the  head  of  the  humerus  in  these  cases  seems  usually  to  be  subspinous. 
The  limitation  of  function  is  similar  to  that  in  traumatic  dislocations. 
Eve  and  Phelps  have  operated  on  such  cases  with  good  functional  result. 
J.  S.  Stone  operated  on  a  case  in  which  the  glenoid  cavity  was  found  to  be 
normal,  and  improvement  in  the  usefulness  of  the  arm  followed.  Lewis 
reduced  a  case  without  incision  in  which  the  reduction  was  permanent,  as 
did  also  Jenni.     In  this  class  of  cases  it  would  seem,  especially  after 


(jAri 


f 


» 


Fig.  433.— Congenital  Dislocation  of  the  Knee.    (Genu  recurvatum  with  club-foot.) 

complicated  labor,  that  a  subspinous  dislocation  of  this  type  was  likely  to 
be  improved  or  cured  by  reduction  or  operation.  When  the  subcoracoid 
or  subacromial  luxation  is  due  to  faulty  development  of  the  glenoid 
cavity  the  outlook  is  not  so  encouraging.  Separation  of  the  epiphysis  of 
the  humerus  occurring  during  delivery  may  simulate  congenital  disloca- 
tion of  the  shoulder. 

Elbow- Joint. — Dislocations  of  the  elbow  are  of  little  practical  surgical 
interest,  the  reported  cases  being  for  the  most  part  curiosities  and  not 
following  any  one  type.     There  are  four  varieties : 

1.  Dislocations  backward  of  the  head  of  the  radius,  with  or  without 
abnormality  of  the  radius  and  ulna  in  the  upper  third  of  the  forearm. 

2.  Forward  and  upward  dislocations  of  the  radius. 

3.  Backward  dislocation  of  the  radius  and  partial  dislocation  of  the 
ulna  with  imperfect  development  of  the  external  condyle. 

4.  Dislocations  of  both  bones  backward. 

Wrist.  — Congenital  dislocations  of  the  wrist  are  for  the  most  part 
associated  with  bony  deformity  and  are  classed  with  club-hand. 

Knee. — Congenital  dislocation  of  the  knee  is  rare;   but  24  cases  are 


448  ORTHOPEDIC   SURGERY. 

reported  by  Phocas,  in  addition  to  which  it  has  been  possible  to  collect 
25  others.  In  Taylor's  list  of  34  cases,  in  18  the  deformity  was  bilat- 
eral, in  16  unilateral;  in  24  of  the  34  the  displacement  was  anterior. 

There  are  two  principal  forms  of  congenital  dislocations  of  the  knee, 
one  in  which  the  tibia  is  dislocated  upward  on  the  femur  and  the  other 
in  which  the  leg  is  hyperextended  as  a  result  of  the  forward  dislocation 
of  the  tibia  on  to  the  anterior  surface  of  the  condyles  of  the  femur. 

Lateral  subluxation  occurs  rarely  and  in  cases  with  other  congenital 
affections.  The  commonest  dislocation  is  the  forward  one  known  as  genu 
recurvation  which  is  found  associated  with  breech  presentation.  The 
condyles  of  the  femur  can  be  felt  at  the  back  of  the  popliteal  space,  and 
the  patella  is  often  small,  occasionally  absent.  Lateral  mobility  is  the 
exception,  and,  as  a  rule,  is  confined  to  the  bilateral  cases  when  other  de- 
formities coexist.  A  case  of  ankylosis  with  anterior  luxation  of  both  tibiae 
has  been  reported  by  Kronlein.  Modifications  in  the  shape  of  the  bones, 
ligaments,  and  cartilages  of  the  knee-joint  have  been  recorded  in  these 
cases. 

The  forward  dislocation  of  the  knee  is  generally  to  be  corrected  by 
manipulation  and  the  application  of  splints  to  the  leg  in  a  corrected  posi- 
tion. Following  these  measures,  apparatus  should  be  applied  to  limit  the 
lateral  motion  if  present  and  to  decrease  the  amount  of  hyperextension 
and  increase  the  amount  of  flexion.  Apparatus  must  be  worn,  of  course, 
till  the  structures  about  the  joints  have  adapted  themselves  to  the  new 
conditions. 

Posterior  dislocation  of  the  knee  has  been  reduced  by  tenotomy,  as 
has  been  done  in  a  case  of  Hamilton  and  by  Sayre.  Massage,  manipula- 
tion, with  or  without  an  anaesthetic,  or  even  osteoclasis,  followed  by  the 
use  of  retentive  apparatus  are  to  be  regarded  as  the  proper  methods  of 
treatment. 

Dislocations  of  the  patella,  described  as  congenital,  although  their 
congenital  origin  is  doubted  by  some  writers,  are  as  follows : 

Displacements  upward  with  lengthening  of  the  patellar  tendon. 

Dislocations  outward  with  absence  or  flattening  of  the  outer  condyle 
of  the  femur. 

Dislocations  outward  with  approximately  normal  condyles. 

In  a  case  of  outward  dislocation  in  a  child  ten  years  old,  apparently 
congenital  in  origin,  operated  upon  by  one  of  the  writers,  the  dislocation 
was  reduced  by  a  long  vertical  incision  at  the  outer  side  of  the  patella 
and  a  reefing  of  the  capsule  at  the  inner  side. 

Ankle.- — Inward  and  outward  dislocations  of  the  ankle  are  recorded  in 
cases  in  which  there  was  bony  defect  of  the  tibia  or  fibula. 


CONGENITAL   DISLOCATIONS.  44ij> 


BlBMOGRAFHY. 

Shoulder. 

Smith:  Dublin  Jour.  Med.  Sc,  L839,  xv..  249. 

Eve:  Trans.  Clin.  Soc,  xxvii.,  299. 

Phelps:  Trans.  Am.  Orth.  Assn.,  1896,  viii..  239. 

Roberts:  Trans.  Am.  Surg.  Assn.,  1895,  xiii.,  885. 

Lewis:  Med.  News.  1895,  lxvi.,  188. 

Scudder:  Am.  Jour.  Med.  Sc.  1898. 

Elbow. 

Bessel-Hagen  :  Langenbeck's  Archiv,  1890-91,  xli.,  420. 
Abbott:  Trans.  Path.  Soc,  1892,  xlii.,  129. 
Herskowitz:  Wien.  med.  Presse,  1888,  xxix.,  218. 
Bergtold:  Annals  of  Surg.,  1891,  xiv.,  870. 
Mitscherlich:  Arch.  f.  klin.  Chir.,  1865,  vi.,  21K. 

Knee. 

Phocas:  Rev.  d'Orthop.,  1891,  ii.,  p.  50. 
Taylor:  Trans.  Am.  Orth.  Assn.,  viii.,  280. 
Maas:  Arch.  f.  klin.  Chir.,  1874,  xvii.,  492. 
Brunner:  Virch.  Archiv,  cxxiv.,  S.  358. 

Patella. 

Zielewicz:  Berliner  klin.  Wochensch.,  1869,  vi.,  253. 
Appel:  Munch,  med.  Wochensch.,  1895,  xlii.,  581. 
Stokes:   Dublin  Journal  of  Medicine,  1865.  xxxix.,  472. 

Ankle. 

Handek:  Zeit.  f.  orth.  Chir.,  1896. 
Hoffa:  Orthop.  Chir.,  p.  706. 
Kirmisson  :  Rev.  de  Chir.,  1897,  624. 
Volkmann:  Deutsche  Zeit.  f.  Chir.,  1872-73,  ii.,  538. 
Cotton  and  Chute:  Trans.  Am.  Orth.  Assn.,  xi.,  316. 
29 


OHAPTEE  XIII. 

INFANTILE    SPINAL   PAEALYSIS. 

Definition. — Etiology.  —  Pathology.  —  Symptoms.  —  Diagnosis. — Differential    diag- 
nosis.— Prognosis. — Treatment. 

Infantile  spinal  paralysis  is  an  affection  which  attacks  chiefly  chil- 
dren in  their  first  dentition.  It  comes  on  with  a  sudden  onset  and  de- 
prives certain  muscles  and  often  an  entire  limb  of  muscular  power,  and 
the  parts  affected  undergo  rapid  atrophy.  The  paralysis  is  a  purely 
motor  one. 

The  pathological  name  of  the  affection  is  acute  anterior  poliomyelitis, 
and  other  common  names  are :  Infantile  paralysis,  essential  paralysis  of 
children,  acute  atrophic  spinal  paralysis,  "  teething  palsy "  or  dental 
paralysis.  Eegressive  paralysis  (Barlow),  myelitis  of  the  anterior  horns 
(Seguin),  myogenic  paralysis  (Bouchut).  German:  Kinderlahmung, 
spinale  Kinderlahmung,  essentielle  Kinderlahmung.  French :  Paralysie 
spinale,  paralysie  infantile,  paralysie  des  petits  enfants,  paralysie  essen- 
tielle de  l'enfance,  tephromyelite  anterieure  aigue  (Charcot),  etc. 

The  disease  was  first  mentioned  by  Underwood J  in  1784,  but  it  waS 
not  then  separated  clearly  from  the  other  kinds  of  paralysis  affecting 
children,  and  it  remained  for  Heine  to  give  the  first  accurate  account  of 
the  disease  in  1840. 

Etiology. 

Little  is  known  of  the  causation  of  infantile  paralysis.  The  disease 
is  usually  limited  to  the  time  of  the  first  dentition  in  children.  Of  250 
cases  (collected  from  Heine,2  Duchenne  the  younger,3  and  Barlow4)  154 
occurred  between  6  months  and  2  years.  Of  SeeligmullerV  71  cases,  90 
per  cent  occurred  before  3  years,  and  of  150  cases  considered  by  Sinkler  ° 
six-sevenths  of  all  cases  occurred  in  the  first  3  years.  In  83  cases  inves- 
tigated by  Schultze  11  were  in  the  first  year  and  31  in  the  second,  while  3 
were  over  5  years  old.     Once  it  occurred  in  a  baby  4  weeks  old.7     Inas- 

J  "Treatise  on  the  Diseases  of  Children,"  London,  7th  ed.,  1826,  p.  251. 

s  Heine  :  "  Ueber  sp.  Kinderlahmung,"  2  Aufl.,  Stuttgart,  1860. 

3  Duchenne  fils:  Arch.  g6n.  de  Med.,  tome  ii.,  1864. 

4 Barlow:  "On  Regressive  Paralysis,"  London,  1878. 

5  Seeligmiiller  :  Gerhardt's  "Handbuch  der  Kinderkrankheiten,"  v.,  1881,  p.  1. 

6 Wharton  Sinkler  :  Keating's  "Encyclopedia,"  p.  683. 

'Schultze  :  "Lehrb.  der  Nervenkrankheiten,"  Stuttgart,  1898,  p.  223. 


INFANTILE    SPINAL   PARALYSIS.  451 

much  as  it  is  well  known  that  children  are  especially  irritable  and  liable 
to  neuroses  of  all  sorts  during  the  time  of  dentition,'  it  is  assumed  that 
this  condition  of  exalted  nervous  irritability  is  sufficient  to  render  the 
cord  most  susceptible  to  any  irritation.  The  disease  has  been  seen  as  > 
early  in  life  as  the  twelfth  day  in  a  case  of  Duchenne's,  and  adults  are  not 
exempt  from  a  similar  affection,  which  is  occasionally  of  traumatic  origin. 

Exposure  to  severe  heat  and  sunstroke  are  mentioned  as  occasional 
causes  of  the  attack  of  paralysis.  Most  cases  occur  during  warm  weather. 
Twenty-seven  of  Barlow's  53  cases  occurred  during  July  and  August, 
and  Sinkler  found  that  in  213  out  of  270  cases  the  disease  occurred  from 
May  to  September  inclusive. 

Exposure  to  cold,  or  chilling  of  the  heated  body,  and  sitting  on  the 
damp  grass  or  on  cold  stones,  are  mentioned  as  occasional  causes  of  the 
attacks  of  paralysis.  Over-exertion  is  reported  as  at  times  the  cause  of 
the  affection.  The  disease  is  also  known  to  occur  during  or  soon  after 
measles,2  scarlet  fever,3  vaccinia,  and  typhus  and  typhoid  fever,  pneu- 
monia, and  erysipelas.4  An  acute  feverish  attack,  like  indigestion,  is 
often  assigned  as  the  cause,  but  inasmuch  as  it  may  be  the  chief  symp- 
tom of  the  onset,  no  weight  can  be  attached  to  it. 

Certain  other  cases  seem  to  come  on  after  a  fall,  and  it  is  quite  pos- 
sible that  a  traumatic  hemorrhage  into  the  substance  of  the  cord  might 
occur,  causing  much  the  same  symptoms  as  anterior  poliomyelitis, 5  but 
such  traumatic  histories  are  rare. 

As  a  matter  of  fact,  the  disease  attacks  healthy  and  unhealthy  chil- 
dren, boys  and  girls  alike,  usually  without  any  demonstrable  cause,  com- 
ing on  in  the  midst  of  perfect  bodily  health,  and  apparently  the  affection 
has  no  dependence  upon  a  hereditary  influence.  It  is  by  far  the  com- 
monest paralysis  in  children  and  in  most  cases  develops  during  the 
night  rather  than  the  day  and  commonly  during  the  hot  months. 

Modern  opinion  rather  inclines  toward  regarding  the  affection  as  in- 
fectious in  origin,  although  the  infecting  organism  has  not  been  definitely 
demonstrated.  Fresh  cases  have  been  investigated  as  to  the  presence  of 
a  microorganism  with  negative  results  for  the  most  part.  Schultze, 6  how- 
ever, in  a  case  of  what  he  considered  anterior  poliomyelitis  of  the  arms 
and  neck  in  a  boy  of  five,  did  a  lumbar  puncture  on  the  thirteenth  day 
and  found  in  the  cerebrospinal  fluid  withdrawn  an  organism  which  he  de- 

1  Henry  Kennedy  :  Dublin  Quart.  Journ.,  ix.,  February  and  May  ;  xxii.,  August 
and  November. 

2  Seeligmiiller :  Loc.  cit. 

3 Roger:  Gaz.  meU,  1871. 

4 Meyer:  "Die  Electricitat  und  ihre  Anwendung  auf  pract.  Medicin,"  Berlin, 
1868,  3d  ed.  * 

5 Taylor:  Med.  Times  and  Gazette,  1879,  vol.  i.,  p.  187;  Duchenne:  Arch.  gen. 
deMeU,1864;  Kennedy:  Dublin  Quarterly,  1850,  and  Frey:  Berl.  klin.  Woch.,  1874. 

6  Munch,  med,  Wochenschr. ,  1898.  No.  38,  p.  1197. 


4 D'2  ORTHOPEDIC    SURGERY. 

scribed  as  the  Weichselbaum-dager  diplococcus.  The  later  history  of  the 
case  Avas  that  of  infantile  paralysis.  As  a  somewhat  similar  form  of 
paralysis  follows  certain  cases  of  cerebrospinal  meningitis,  this  evidence 
cannot  be  accepted  as  conclusive. 

The  affection  occurs  at  times  as  an  epidemic  which  lends  force  to 
the  view  of  its  infectious  character.  Such  epidemics  have  been  reported 
from  time  to  time.  The  earliest  was  in  1843. '  Medin  -  reported  44 
cases  occurring  in  Stockholm  in  the  summer  of  1887.  There  were  three 
deaths,  and  although  in  general  the  ordinary  type  of  infantile  paralysis 
was  followed,  a  few  aberrant  cases  were  seen.  Briegleb ;i  reported  an 
epidemic  in  1890. 

The  epidemic  reported  by  Caverly l  in  Vermont,  around  Rutland,  in 
the  summer  of  1894,  was  very  extensive  and  very  severe.  The  epidemic 
included  132  cases,  and  18  cases  were  fatal.  The  cerebral  tracts  were  in 
several  cases  involved.  An  epidemic  in  Australia  was  reported  by  Alston 
in  1897,  consisting  of  14  cases.5  An  epidemic  in  Cherryheld,  Me.,  was 
reported  by  Madison  Taylor.  There  were  7  cases  with  1  fatality.0  W. 
Pasteur7  reported  in  1896  an  epidemic  occurring  in  7  members  of  the 
same  family.  A  very  careful  investigation  of  an  epidemic  occurring 
in  North  Adams,  Mass.,  was  made  by  Brackett. 8  Ten  cases  were  seen 
and  examined  which  in  general  were  of  a  more  severe  type  than  ordinary 
cases.  The  initial  fever  was  high,  the  distribution  of  paralysis  was  on 
the  whole  more  extensive.  The  sphincters  were  at  times  involved,  and 
prolonged  hyperesthesia  was  found  in  the  severer  cases.  These  features 
seem  in  general  to  characterize  the  epidemic  cases  as  described  by  others. 
At  North  Adams  all  of  the  cases  but  one  occurred  along  the  banks  of  the 
two  rivers  flowing  through  the  town ;  no  other  common  etiological  factor 
could  be  found. 

Pathology. 

The  study  of  autopsies9  in  recent  cases  of  infantile  paralysis  has  re- 
sulted in  the  opinion  among  recent  writers  that  the  entire  gray  matter  of 
the  cord  is  the  seat  of  interstitial  inflammation  and  that  the  changes  in 

1  Colmer :  Am.  Jour.  Med.  Sciences,  1843. 

2  Medin:  Proceedings  Tenth  Int.  Cong.,  vol.  ii.,  div.  iv. 
'Briegleb:  Inaug.  Diss.,  Jena,  1890. 

4  Journ.  Am.  Med.  Assn.,  January  4th.  189(1 

5  Australian  Med.  Gaz.,  April  24th,  1897. 
"Boston  Med.  and  Surg.  Journ.,  cxxix..  504. 
'Trans.  Clin.  Soc.  of  London,  1896,  p.  143. 

8 Trans.  Am.  Orth.  Assn.,  vol.  xi.,  p.  132. 

9 Goldscheider :  Zeit.  f.  klin.  Med.,  xxiii.,  1893,  p.  494;  Dauber:  Zeit.  f. 
Nervenheilkunde,  vol.  iv.  ;  Siemerling:  Arch.  f.  Psychiatrie,  xxvi.,  267  (with  litera- 
ture to  1894). 


INFANTILIS    SPINAL    PARALYSIS. 


}:>:; 


the  ganglion  cells  are  secondary'  (Sachs),  (ioldscheider's  study  would 
make  it  appear  that  the  blood-vessels  are  first  affected  and  that  from 
these  the  neuroglia  is  attacked,  and  that  the  changes  in  the  ganglion 


y1G.  434—  Poliomyelitis  Anterior;   Part  of  an  Acute  Myelitis.     Death  at  eight  days.    Section  through 
lumbar  segment,  showing  disruption  of  anterior  gray  matter  from  hemorrhage.    (Sachs.) 

cells  are  degenerative  and  secondary  in  them  as  well  as  in  the  nerve 
fibres.  The  cases  of  Siemerling  are  confirmatory,  and  both  sets  lead  to 
the  view  that  the  inflammation  is  interstitial  and  not  parenchymatous. 

The  process  may  involve  a  few  segments  of  the  cord,  or  it  may  involve 
a  greater  part  of  the  cord  and  extend  to  the  medulla  and  pons.  The 
larger  ganglion  cells  of  the  anterior  horns  in  the  affected  area  disappear 
and  the  ones  that  remain  are  shrunken  and  the  cell  processes  have  dis- 
appeared. The  entire  gray  matter  of  the  affected  side  shrinks,  and  even 
the  white  matter  is  smaller  than  that  of  the  other  side.  The  columns  of 
Clarke  disappear  and  the  anterior  nerve  roots  become  smaller  than  those 
of  the  other  side. 

Atrophic  changes  soon  take  place  in  the  paralyzed  limb.      Sometimes 

1  Von  Kahlden:  Cent.  f.  Path..  September  14th,  1894  (Charcot's  view). 


454 


ORTHOPEDIC    SURGERY. 


the  atrophy  affects  the  bones,  which  become  shortened  even  to  the  extent 
of  affecting  the  length  of  a  limb  by  several  inches.  At  the  same  time 
the  affected  limb  grows  comparatively  smaller  in  circumference  than  that 


vr.*'.-'- 


if  Yzsvm,}. 


Fig.  435.— Poliomyelitis  Anterior  of  Old  Standing.    Disappearance  of  ganglion  cells  on  right  side  and 
shrinking  of  right  half  of  cord.    Cervical  region.    (Sachs.) 


of  the  opposite  side.     This  is  frequently  the  result  of  retarded  growth 
rather  than  of  real  wasting,   but  both  factors  at  times  enter  into  the 


Fi<;.  43<'i.— Anterior  Poliomyelitis.    Chronic  stage;  section  through  sixth  cervical  segment ;  diminution 
of  anterior  gray  matter  and  of  entire  half  of  right  side.    (Sachs.) 

change.     In  other  instances,  even  in  severe  cases,  the  bones  seem  but 
little  affected,  while  the  atrophy  of  the  muscles  is  very  marked. 

The  epiphyses  are  stunted,  and  the  ligaments  become  thin  and  loose, 
and  dislocations  and  distortions  of  the  joints  are  favored.     It  is  in  the 


INFANTILE   SPINAL   PARALYSJS.  455 

muscles  that  the  most  notable  changes  are  found.  These  waste  rapidly 
and  become  flabby  to  the  touch;  and  microscopic  examination  shows  a 
loss  of  striation  followed  by  a  granular  degeneration  of  the  fibres  until 
little  is  left  beyond  muscle  corpuscles  and  fat  granules  contained  in  sar- 
colemma.      This,  of  course,  is  clearly  more  than  the  atrophy  of  disuse' 

That  poliomyelitis  represents  an  acute  inflammatory  condition  of  the 
anterior  gray  matter  of  the  spinal  cord  is  conceded  on  all  sides,  but  the 
question  arises,  what  the  origin  of  such  inflammation  may  be.  The  only 
satisfactory  explanation  at  the  present  day  is  to  suppose  that  the  inflam- 
mation is  the  result  of  an  acute  infection  which  happens  to  be  located  in 
the  spinal  cord,  just  as  other  infectious  diseases  show  a  predilection  for 
other  sites  in  the  body.  The  microbic  origin  has  not  yet  been  satisfac- 
torily demonstrated,  but  all  the  clinical  facts  point  toward  this  view,  and 
the  close  dependence  of  the  myelitic  process  upon  the  distribution  of  the 
blood-vessels  lends  further  color  to  this  theory.'2 

Symptoms. 

In  general  the  clinical  history  of  the  disease  falls  into  three  stages : 

(a)  The  onset,  to  which  stage  belong  the  acute  febrile  symptoms  and 
the  development  of  paralysis. 

(6)  The  stage  of  convalescence,  which  begins  at  the  time  of  the  full 
development  of  the  paralysis,  and  is  followed  by  a  brief  stationary  period, 
and  finally  rapid  and  then  slower  improvement  until  a  stationary  period 
is  reached. 

(c)  The  stage  of  deformity  in  which  wasting  of  the  affected  limb  is 
present  and  static,  paralytic,  and  contraction  deformities  have  supervened. 

No  arbitrary  subdivision  of  the  classes  of  symptoms  will  be  made, 
because  in  reality  the  stages  run  into  each  other  so  gradually  that  it 
seems  unjustifiable  to  divide  them  so  practically. 

Infantile  paralysis  is  oftenest  ushered  in  by  a  mild  or  severe  febrile 
attack,  which  presents  no  definite  characteristics  to  distinguish  it  from 
any  ordinary  attack  of  cold  or  indigestion. 3  The  elevation  of  temperature 
is  not  excessive,  commonly  from  100°  to  102°  F.,  sometimes  even  104°. 
With  this  fever  are  apt  to  be  associated  vomiting,  convulsions,  giddiness 
or  other  cerebral  disturbance,  sometimes  even  delirium.  Older  children 
complain  of  pain  in  the  back  and  limbs.  There  is,  as  a  rule,  no  warning 
of  the  attack,  although  Seeligmuller  has  noted  at  times  a  disinclination 
to  walk  or  stand  as  much  as  usual  for  some  days  preceding — a  fact  quite 
in  accordance  with  Lange's  theory  that  over-exertion  of  the  muscles  has 
much  to  do  with  the  production  of  the  disease.     Convulsions  may  be 

'Gowers:  "Dis.  of  Nerv.  Syst.,"vol.  i.,  253;  Jacob  v.  Heine:  Loc.  cit. 
2 Sachs:  "The  Nervous  Diseases  of  Children,"  New  York,  1895. 
3  Vogt :  "Ueber  die  essentielle  Lahmung  der  Kinder." 


456  ORTHOPEDIC   SURGERY. 

present,1  ami  when  they  occur  they  are  usually  followed  by  a  period  of 
unconsciousness.  The  feverish  attack  at  the  onset  may,  however,  be 
very  severe,"  at  times  lasting  two  or  three  days  (or  even  weeks)  before 
the  paralysis  appears.  More  commonly,  however,  it  is  very  slight  and 
scarcely  noticed.  In  certain  rare  cases,  two  or  even  three1'  attacks  of 
fever  are  noted,  each  followed  by  an  increase  in  the  paralysis.1  Paiu  of 
a  rheumatic  character  in  the  back  and  limbs  is  a  common  initial  symp- 
tom.' In  certain  cases6  all  feverish  and  other  symptoms  are  absent7  at 
the  onset,  and  the  child  is  suddenly  discovered  to  be  paralyzed  in  one  or 
more  limbs.  Such  paralysis  comes  on  oftenest  in  the  night,  but  it  has 
been  observed  to  come  on  quietly  in  the  daytime,  while  the  child  was  at 
play.-  In  these  cases  there  may  be  no  succeeding  illness,  and  the  paraly- 
sis is  the  only  symptom  throughout. 

Diarrhoea,  vomiting,  general  hyperaesthesia,  and  much  nervous  irrita- 
bility are  other  symptoms  which  often  accompany  the  onset  of  the  paraly- 
sis. During  the  first  few  days  there  may  be  paralysis  of  the  bladder 
with  retention  or  incontinence  of  urine,  but  it  disappears  after  a  few  days 
or  weeks.  Pain  is  a  symptom  but  little  noted  in  infantile  paralysis,  but 
it  is  not  uncommon,  nor  does  it  indicate  of  itself  the  presence  of  any 
additional  pathological  process. 

The  paralysis  itself  very  quickly  becomes  manifest  and  reaches  its 
maximum  within  a  few  hours  of  the  attack,  or  within  a  day  or  two,  ex- 
cept in  rare  cases.  Having  reached  its  maximum  and  remained  station- 
ary for  a  short  time,  improvement  almost  invariably  begins.  In  rare 
cases  improvement  begins  immediately  after  the  attack,  and  proceeds  to 
complete  recovery.  These  are  the  cases  which  are  spoken  of  as  "  tem- 
porary spinal  paralysis."  The  more  common  course  is  for  the  paralysis 
to  remain  nearly  stationary  for  a  time  varying  from  two  to  six  weeks,  and 
then  to  improve,  at  first  rapidly  and  then  more  slowly,  for  three  or  four 
months.  After  six  months  have  passed,  further  spontaneous  improve- 
ment is  unusual. 

Vascular  changes  become  very  marked.  The  temperature  of  the  limb 
is  much  lower  than  that  of  the  other.  The  limb  is  generally  bluish,  with, 
a  superficial  stagnation  of  the  blood,   on  account  of  an  atrophy  of  the 

'  Jacobi :  Pepper's  "  Syst.  of  Medicine."  vol.  ii. 

'-'  Erb  :  Ziemssen's  "  Handbuch,"  xi.,  12  ;  Henoch  :  "  Vorles.  iiber  Kinderkr.,"  2te 
Aufl.,  1881. 

'■Laborde:  Op.  cit,  p.  8. 

4  Althaus :  "On  Inf.  Par.  and  some  allied  Diseases  of  the  Sp.  Cord,"  London, 
1878,  p.  12. 

5  Duchenne  fils  :  Arch.  gen.  de  Med.,  1864,  37. 
6Laborde:  "De  la  Paralysie  de  l'Enfance." 

;  Seeligrnuller  in  Rilliet  et  Barthez'  "Traite  des  Mai.  de  PEnfance,"  vol.  ii., 
p.  551. 

■  M.  P.  .Jacobi:  Am.  Journ.  of  Obst.,  May,  1874. 


INFANTILIS    SPINAL   PARALYSIS. 


457 


blood-vessels  and  consequent  diminution  of  their  calibre,  and  when  the 
blood  is  pressed  out  of  the  surface  capillaries  by  the  finger  it  returns 
slowly.  On  account  of  this  vascular  sluggishness  ulcers  may  form, 
which  are  slow  to  heal  and  very  painful.  The  limb  even  very  early  loses 
its  normal  appearance,  and  the  flaccid  undeveloped  look  of  tin;  foot  or 
hand  is  most  noticeable. 

Atrophy  of  the  affected  muscles  begins  to  be  perceptible  a  few  weeks 
after  the  onset  of  the  paralysis,  while  the  loss  of  striatum  in  the  muscu- 
lar fibres  can  be  detected  with  the  microscope  within  two  ov  three  days 
the  attack.1  The  muscles  may  be  tender  to  the  touch  during  the  time 
that  they  are  wasting  so  fast,  especially  in  adults  and  older  children. 
Muscles  seriously  affected  are  toneless  and  flaccid  from  the  first,  and  in 
the  late  stages  of  wasting  scarcely  any  volume  of  muscle  seems  left  when 
the  limb  is  grasped  with  the  hand. 

The  paralysis  is  a  purely  motor  one,  and  although  tingling  and  formi- 
cation may  be  present,  sensation  is  very  rarely  affected.  The  reflexes 
are  abolished  in  the  affected  limb  if  the  implication  of  the  extensor  mus- 
cles of  the  thigh  be  enough  to  do  away  with  the  knee  jerk  of  the  affected 
side. 

Sometimes  after  an  attack  the  paralysis  may  seem  to  be  general,  but 
the  probabilities  are  that  after  improving  in  general,  the  loss  of  power 
will  eventually  be  localized  in  one  limb,  and  that  if  one  limb  originally 
is  paralyzed  the  likelihood  is  very  great  that  a  certain  amount  of  power 
will  be  regained,  leaving  only  certain  groups  of  muscles  permanently 
paralyzed. 

Distribution.— The  paralysis  in  its  distribution  is  monoplegic  in  more 
than  half  the  cases,  as  a  consolidation  of  the  tables  of  Duchenne  and 
Seeligmiiller  will  show. 


f  hie  leg  paralyzed,     .... 

One  arm        "  .... 

Both  legs      "  .... 

Both  arms    " 

All  four  extremities  paralyzed, 

Hemiplegic  paralysis, 

Orossed  paralysis,     .... 

Muscles  of  trunk  and  abdomen  paralyzed, 


74 

23 

23 

3 

7 
3 
3 

1 


137 

The  great  preponderance  of  paralysis  of  the  lower  extremities  is  to 
be  noted,  and  the  liability  to  paralysis  increases  even  from  the  thigh  to 
the  foot,  and  when  improvement  begins  in  a  case  in  which  both  an  upper 
and  lower  extremity  are  paralyzed,  the  improvement  begins  first  in  the 


"11.  W.  Berg:  Wood's  "  Ref.  Handbook,"  vol.  v.,  p.  504. 


458 


ORTHOPEDIC   SURGERY. 


arm.  Commonly  certain  groups  of  muscles  are  attacked,  and  when  ad- 
jacent muscles  are  affected  the}'-  seem  to  be  selected  at  random  oftener 
than  by  functional  or  anatomical  association.  In  the  leg,  the  extensors 
and  the  peronei  are  the  muscles  oftenest  affected.  The  glutei  are  never 
affected  alone,  but  they  commonly  share  in  any  extensive  paralysis  of  the 
leg.  In  the  arm  the  deltoid  suffers  oftener  than  any  other  arm  muscle, 
either  alone  or  in  association  with  other  muscles.  The  "  upper-arm  type  " 
of  paralysis,  which  Erb  has  described,  consists  of  the  simultaneous  affec- 
tion of  the  cleltoid,  supra-  and  infraspinatus,  the  biceps,  and  the  supina- 
tors.     There  is  also  a  "  forearm  type  "  described  by  Eemak  l  in  which, 

as  in  lead  paralysis,  the  extensor  muscles  of 
the  hand  are  paralyzed  while  the  supinator 
longus  is  spared.  The  serratus  magnus  is 
sometimes  affected  as  well  as  the  trapezius 


FIG.  437.— Paralysis  of  Left  Arm 
Muscles,  deltoid  and  serratus  mag- 
nus. 


Fig.  438.— Kyphosis  in  Paralysis  of  the  Back  Muscles.    (Gowera.) 


and  pectoralis  major.  The  neck  muscles  are  very  seldom  affected  and 
the  muscles  supplied  by  the  cranial  nerves  only  rarely. 

The  muscles  of  the  back  may  be  paralyzed  and  the  patient  be  unable 
to  sit  erect,  or  if  the  distribution  of  the  paralysis  is  uneven  lateral  curva- 
ture may  result — a  state  of  affairs  often  made  worse  by  allowing  the 
patient  to  sit  erect  while  the  muscles  are  still  weak.  The  diaphragm  is 
occasionally  paralyzed.  In  those  rare  cases  of  paralysis  of  the  abdominal 
muscles,  the  patient  leans  back  to  a  very  marked  degree,  missing  the 
restraining  action  of  the  abdominal  muscles.  There  are,  finally,  cases  of 
universal  paralysis  in  which  death  soon  takes  place  from  interference  with 
respiration . 

The  sequelte  of  the  disease  are  few.     Progressive  muscular  atrophy 


'Remak:  Arch.  f.  Psych.,  Baud  ix.,  1878-79,  p.  510. 


INFANTILE   SPINAL   PARALYSIS.  4:59 

has  been  several  times  observed  to  start  from  the  diseased  limb,  and  the 
symptoms  of  lateral  sclerosis  at  other  times  have  been  seen  to  develop, ' 
but  such  occurrences  are  very  rare. 

Deformities. — The  deformities  which  come  on  after  infantile  paralysis 
are  late  events  in  the  history  of  the  disease  and  rarely  develop  until 
at  least  some  months  after  the  attack.  They  are,  as  a  rule,  progressive 
in  their  character  and  the  end  results  are  often  such  extreme  distortions 
that  the  affected  limb  is  useless.  The  deformities  fall  into  two  chief 
classes:  (1)  deformities  due  to  trophic  changes,  such  as  bone  shortening, 
etc. ;   (2)  deformities  due  to  muscular  paralysis. 

(1)  The  first  class  is  comparatively  unimportant;  shortening  of  the 
paralyzed  arm  or  leg  may  take  place  with  atrophy  of  the  bone  in  every 
direction,  so  that  a  liability  to  fracture  is  of  course  a  necessary  conse- 
quence. Shortening  of  the  arm  is  comparatively  unimportant  in  itself, 
but  shortening  of  the  leg  is  likely  to  induce  lateral  curvature  of  the  spine 
from  the  necessarily  tilted  position  of  the  pelvis'  due  to  the  unequal 
length  of  the  legs. 

(2)  The  deformities  of  the  second  class,  which  are  the  result  of  mus- 
cular paralysis,  are  manifold  and  form  the  great  bulk  of  the  cases  of  de- 
formity in  anterior  poliomyelitis.  As  a  rule  they  do  not  appear  earlier 
than  two  or  three  months  after  the  onset  and  more  commonly  not  for 
many  months. 

For  clinical  consideration  they  fall  into  two  groups :  deformities  caused 
by  contraction,  and  deformities  due  to  laxity  of  the  muscles  and  ligaments. 
Volkmann,  on  the  ground  of  Hitter's  investigations,  explained  nearly  all 
the  deformities  on  mechanical  grounds,  urging  that  the  deformities  were 
developed  partly  by  reason  of  the  weight  of  the  limbs  concerned  and  the 
position  which  they  assumed  when  at  rest,  and  partly  because  of  the 
muscular  insufficiency  of  the  affected  limbs  which  allowed  the  articular 
surfaces  to  be  subjected  to  an  excessive  pressure  when  brought  into  use, 
which  had  the  effect  of  gradually  pressing  them  into  abnormal  position. 
The  earlier  idea  had  been,  however,  that  they  were  brought  about  by  the 
unopposed  action  of  the  muscles  which  were  not  affected.  Probably  both 
factors  are  active  in  the  causation  of  deformity. 

A  word  should  be  said  in  regard  to  the  reason  of  the  more  severe 
affection  of  the  anterior  leg  and  thigh  muscles  than  of  the  posterior 
muscles  in  nearly  all  cases.  The  theory  has  been  advanced  that,  after 
a  paralysis  of  the  leg,  the  limb  lies  flaccid  and  nearly  powerless,  the 
toes  drop,  and  if  the  sitting  posture  is  assumed,  the  knees  flex  and  the 
legs  hang  heavily  down.  As  a  result  of  this,  the  anterior  muscles  are 
always  pulled  upon  and  slightly  stretched,  while  the  posterior  ones  are 

^Gowers:  "Dis.  of  Nerv.  Syst.,"  vol.  i.,  p.  262. 

2 Bradford:  "Etiology  of  Lateral  Curvature,"  Boston  Med.  and  Surg.  Jour., 
1886.  cxiv. 


460  ORTHOPEDIC   SURGERY. 

lax.  If  all  the  muscles  are  equally  affected,  this  very  factor  may  be 
enough  to  make  a  great  difference  in  the  ultimate  usefulness  of  the  two 
groups.  Stretched  muscles  are  notoriously  at  a  disadvantage,  so  far  as 
recovery  goes,  in  any  diseased  condition,  and  muscles  at.  rest  are  much 
more  favorably  situated.  So  that  this  very  point  may  determine  in  a 
measure  the  relative  amount  of  recovery  in  the  two  groups. 

Moreover,  muscular  contraction  and  consequent  deformity  occur  only 
.  in  cases  in  which  a  muscle  has  been  allowed  to  remain  for  a  long  time  in 
a  shortened  or  stretched  condition.  For  this  reason,  it  is  highly  impor- 
tant to  support  and  restrain  the  affected  limb  in  a  normal  position  (the 
toot  at  a  right  angle  to'  the  leg,  etc.). 

The  common  deformities  from  infantile  paralyis  which  come  to  the 
orthopedic  surgeon  for  treatment  are  those  of  the  lower  extremity.  Con- 
sidered in  detail,  it  is  best  to  begin  with  deformities  at  the  hip-joint  and 
then  to  pass  on  to  the  consideration  of  knee-joint  deformities  and  distor- 
tions of  the  foot. 

Deformities  of  the  Ley. — Paralysis  maybe  complete  and  a  flail-like 
leg  be  the  result,  with  wasted  muscles,  and  loose  distorted  joints,  incapa- 
ble of  motion  or  bearing  weight.  Such  a  limb  is  spoken  of  as  "  jambe  de 
Polichinelle." 

But  more  commonly  the  paralysis  is  partial  rather  than  complete. 
The  muscles  of  the  thigh  commonly  affected  are  the  internal  and 
anterior  groups.  This  constitutes  a  serious  combination  and  renders 
walking  difficult;  not  only  is  the  leg  abducted  with  a  tendency  to  ever- 
sion,  but  the  extensor  thigh  muscles  cannot  hold  the  knee  rigid  as  is 
necessary  in  walking,  the  leg  giving  way  whenever  weight  is  put  upon  it. 
The  glutei  are  generally  implicated  in  this  paralysis,  and  the  contraction 
which  is  likely  to  result  from  this  paralysis  is  flexion  of  the  thigh  alone 
or  with  abduction  of  the  leg,  a  condition  always  associated  with  flexion 
of  the  knee  and  talipes  equino-varus. 

Flexion  deformity  at  the  hip  produces  in  time  a  most  marked  lordosis 
in  the  back.  When  the  patient  stands  with  the  leg  dangling,  the  weight 
of  it  drags  upon  the  pelvis  and  rotates  it  on  a  transverse  axis,  a  compen- 
sation which  makes  it  possible  for  the  leg  to  hang  as  nearly  as  possible 
perpendicularly.     This  deformity  is  marked  and  troublesome. 

At  the  knee,  contraction  in  the  flexed  position  (with  often  a  tendency 
to  subluxation  of  the  tibia  backward)  is  found,  and  in  the  more  severe 
cases  decided  knock-knee.  At  other  times  when  laxity  rather  than  con- 
traction predominates,  hyperextension  of  the  knee  is  observed  and  some- 
times lateral  mobility  also  exists.  In  severe  cases  of  this  type  in  which  the 
deformity  has  been  rectified  by  mechanical  or  operative  means,  the  tibia 
lies  in  a  plane  decidedly  posterior  to  that  of  the  femur.  The  same  may 
be  said  of  the  knock-knee  which  results  from  the  greater  promi- 
nence of  the  internal  condyle  of  the  femur.     The  flexion  may  have  been 


INFANTILE    SPINAL    PARALYSIS. 


461 


overcome,    but    still    a   decided  degree  of    knock-knee    may   remain    in 
the  corrected  leg. 

Hyperextension  of  the  knee  may  also  increase  to  a  very  marked 
degree  and  is  commonly  associated  with  talipes  valgus.  This  hyper- 
extension results  in  cases  in  which  the  anterior  muscles  are  weak  and  fail 
to  hold  the  knee  extended  when  walking  is  attempted.     In  these  cases 


Fig.  440.— Standing   Position   of  Valgus  in  In- 
fantile Paralysis. 


Fig.  439.— Infantile  Paralysis.    Contractures  of  right 
leg.    (Weigel.) 


Fig.  441.— Talipes  Calcaneus. 


the  patient  throws  the  weight  of  the  body  upon  the  fully  extended  knee 
and  the  strain  falls  upon  the  ligaments  rather  than  on  the  muscles.  The 
posterior  ligaments  yield  in  time  to  this  repeated  weight  and  the  patient 
obtains  for  a  time  a  better  bearing.  The  same  deformity  is  favored  by  a 
tendency  which  these  patients  have  to  lean  with  the  hand  upon  the  knee 
when  rising  from  a  chair. 

There  is  a  tendency  to  outward  rotation  of  the  tibia  upon  the  f&mur 


4:62 


ORTHOPEDIC   SURGERY. 


in  cases  of  long-standing  paralysis  of  the  leg.  In  this  case  the  eversion 
of  the  foot  in  walking  is  a  troublesome  complication. 

Inasmuch  as  paralyses  of  the  anterior  tibial  muscles  and  the  peronei 
are  the  most  frequent, '  the  deformities  that  one  sees  of tenest  are  talipes 
equino-varus,  or,  if  the  peronei  are  intact,  talipes  equinus.  Pure  talipes 
varus  from  this  cause  is  not  common. 

It  will  be  seen  that  hyperextension  of  the  knee  is  favored  in  cases 
in  which  talipes  equinus  exists,  as  by  that  means  alone  the  foot  can  be 
placed  flat  on  the  ground. 

Talipes  calcaneo-valgus  and  pure  flat-foot  are  favored  by  lax  liga- 
ments, and  the  latter  may  be  a  progressive  deformity,  which  increases 


Fig.  442.— Pes  Cavus. 


Fig.  443.— Both  Feet  of  Patient  with  Paralysis 
of  All  Posterior  Muscles  Except  the  Peronei. 
(Goldthwait.) 


until  a  stage  is  reached  in  which  the  inner  malleolus  almost  touches  the 
giound  and  the  foot  can  be  flexed  until  the  dorsum  touches  the  skin  over 
the  tibia.  The  bearing  of  body  weight  on  a  foot,  the  ligaments  and 
muscles  of  which  are  weak,  tends  to  produce  flat-foot. 

Pure  talipes  calcaneus  seems  to  be  the  result  of  the  paralysis  of  the  pos- 
terior calf  muscles  combined  with  the  action  of  gravity  and  superincum- 
bent weight.  What  is  known  as  pes  cavus  is  more  common  than  pure 
talipes  calcaneus. 

The  order  of  frequency  of  the  different  forms  of  deformity  from  an- 
terior poliomyelitis  is  as  follows:  (1)  talipes  equino-varus;  (2)  calcaneo- 
valgus;  (3)  equinus;  (4)  calcaneus  or  pes  cavus. 

Deformities  of  the  arms  are  comparatively  uncommon  as  the  result  of 
infantile  paralysis.     The  least  infrequent  of  these  results  from  the  paraly- 


1  Ross:  "Dis.  of  Nerv.  Syst.,»  Wm.  Wood  &  Co.,  1878,  p.  942. 


INFANTILE    SPINAL   PARALYSIS. 


463 


sis  of  the  deltoid.  In  addition  to  the  inability  to  raise  the  arm  from 
the  side,  there  is  a  flattening  of  the  shoulder  and  a  prominence  of  the 
acromion  process,  and  the  shoulder  presents  an  angular  rather  than  a 
rounded  outline.  The  ligaments  are  loosened,  and  the  arm  hangs  loosely, 
so  that  in  some  cases  a  wide  gap  may  be  ob- 
served between  the  acromion  and  the  humerus. 

Any  distortion  of  the  arm  and  hand  further 
than  the  flaccid  condition  resulting  from  the 
paralysis  is  quite  rare.  If  contraction  does 
occur,  it  follows  the  type  to  be  seen  in  adult 
hemiplegia:  flexion  of  the  elbow,  hand,  and 
fingers.  The  commonest  paralysis  of  the  hand 
is  one  affecting  the  adductor  muscles  of  the 
thumb,  as  a  result  of  which  the  thumb  is  drawn 
back  to  a  level  with  the  other  fingers  and  the 
power  to  oppose  it  to  the  other  fingers  in  grasp- 
ing is  thus  lost.  Flexion  of  the  hand  and 
fingers  may  be  observed,  or  flexion  of  the  hand 
with  some  mobility  of  the  fingers. 

Infantile  paralysis  of  the  sterno-mastoid 
muscle  is  recognized  as  an  occasional  cause  of 
wry-neck.  Paralysis  of  the  intercostal  muscles 
rarely  causes  deformity,  but  Gowers  saw  a  case 
in  which  a  permanent  depression  in  one  side  of 
the  thorax  resulted  from  such  a  paralysis.  Pa- 
ralysis of  the  erector  spinas  muscles  results  in  a  permanent  arching  of  the 
spine  and  inability  to  sit  erect.  Paralysis  of  the  abdominal  muscles 
causes  lordosis. 

Lateral  curvature  of  the  spine  results  from  infantile  paralysis  in  one 
of  three  ways. 

(1)  Prom  the  inequality  in  the  length  of  the  legs  (due  to  paralysis 
of  one  leg),  causing  tilting  of  the  pelvis.  (2)  From  the  unilateral  paraly- 
sis of  the  muscles  directly  controlling  the  vertebral  column,  which  might 
be  either  a  paralysis  of  the  intrinsic  spinal  muscles  or  of  the  erector 
spinse  group  on  one  side.  (3)  From  faulty  spinal  attitudes  assumed  in 
consequence  of  some  paralysis  elsewhere,  as  in  paralysis  of  one  arm,  or 
of  the  serratus  magnus,  or  even  of  the  sterno-mastoid.  These  cases  have 
been  more  particularly  considered  under  the  head  of  lateral  curvature. 

Dislocations  from  Infantile  Paralysis. — Dislocation,  complete  or  par- 
tial, belongs  to  the  more  uncommon  of  the  complications  of  infantile 
paralysis  and  characterizes  severe  cases. 

Dislocation  of  the  hip  is  the  one  most  commonly  met  and  it  takes 
place  either  spontaneously  or  in  consequence  of  weight  being  borne  upon 
a  limb  which  is  improperly  supported  by  its  ligaments.     It  occurs  only 


Fig.  444.  —  Talipes  Equinus 
from  Infantile  Paralysis,  with 
Slight  Valgus. 


-k;-t 


ORTHOPEDIC    SURGERY. 


in  cases  in  which  the  paralysis  is  severe  and  of  long  standing,  and  it  may 
disable  the  leg  on  account  of  the  laxity  with  which  the  femur  articulates 
with  the  pelvis.  A  shortening  of  one  or  two  inches  may  be  present,  as 
the  dislocation  is  generally  on  to  the  dorsum  of  the  ilium ;  but  sometimes 
it  takes  the  form  of  a  laxity  of  the  joint  in  all  directions,  so  that  the 


mm 


fir 


Fig.  44-r>.—  Dislocation  of  Hip,  the  Result  of  Infantile  Paralysis.    In  this  position  the  head  of  the  femur 
(left)  is  in  place,  but  with  abduction  it  slips  out  again. 


head  may  be  thrown  into  any  position  by  manipulation  of  the  shaft. 
Most  dislocations  of  the  hip  are  inconvenient  chiefly  because  of  the  short- 
ening and  insecurity  which  follow  the  displacement  of  the  head  of  the 
bone.  But  the  head  of  the  bone  in  a  year  or  two  becomes  often  quite 
firmly  fixed  in  its  new  position  and  such  legs  are  sometimes  nearly  as 
serviceable  as  they  were  before.  Dislocation  may,  however,  occur  before 
any  weight  is  borne  upon  the  affected  limb,  by  the  spontaneous  action  of 


INFANTILE   SPINAL   PARALYSIS.  465 

the  muscles,  as  in  a  patient  eighteen  months  old  in  the  experience  of  one 
of  the  writers  in  which  dislocation  of  one  hip  took  place  at  the  age  of  three 
months.  In  this  case  the  dislocation  was  reduced  under  an  anaesthetic, 
and  by  the  application  of  a  plastei-of-Paris  bandage  the  head  of  the 
femur  was  permanently  retained  in  the  acetabulum.  These  dislocations 
are  rarely  attended  by  much  pain  and  are  often  overlooked  by  the 
parents. 

Laxity  of  the  knee-joint,  so  that  the  joint  surfaces  slip  by  each  other 
in  the  motions  of  the  joint,  is  a  less  common  affection,  but  is  sometimes 
seen.     In  these  cases  the  joint  is  subluxated  at  each  step. 

The  subluxation  of  the  tibia  in  severe  cases  of  knee  flexion  and  the 
dislocation  of  the  shoulder  after  paralysis  of  the  deltoid  muscle  have  been 
already  mentioned. 

Diagnosis. 

In  typical  cases  the  diagnosis  of  infantile  paralysis  is  not  difficult. 
But  in  other  than  typical  cases  the  recognition  of  the  disease  may  be  ex- 
tremely difficult,  and  it  is  never  easy  to  establish  a  positive  diagnosis  in 
the  initial  stage.  At  that  time  the  occurrence  of  localized  pain  may  be 
a  misleading  symptom,  and  sensitiveness  of  the  affected  limbs  may  sug- 
gest rheumatism.  The  occurrence  of  convulsions  and  unconsciousness 
may  divert  the  attention  to  the  brain,  and  all  sorts  of  side  issues  may  be 
suggested  by  the  manifold  symptoms  of  the  onset  of  the  disease.  The 
affection  is  often  wrongly  classed  as  cerebrospinal  meningitis  at  the  earli- 
est stage,  as  the  head  is  sometimes  drawn  backward  in  severe  cases. 

The  diagnostic  points  upon  which  the  practitioner  must  rely  are 
the  sudden  onset,  a  motor  paralysis,  rapid  muscular  wasting,  the  dis- 
tribution of  the  paralysis  (mostly  monoplegic  and  very  rarely  hemi- 
plegic),  and  the  loss  of  the  tendon  reflex.  Diagnosis  by  the  deter- 
mination of  the  electrical  reaction  of  the  muscles  requires  especial 
training  and  skill,  although  it  is  distinctive  and  the  most  reliable  test 
at  our  command. 

Electrical  Condition  of  the  Muscles. — The  electrical  reactions  in  infan- 
tile paralysis  are  clearly  marked  and  characteristic  when  they  can  be 
obtained.  Faradic  irritability  of  the  affected  muscles  and  nerves  be- 
gins to  diminish  within  a  day  or  two  of  the  onset  of  the  paralysis,  and 
in  muscles  severely  affected  the  electric  irritability  disappears  entirely ; 
in  the  muscles  less  seriously  involved  it  is  merely  diminished.  This  con- 
stitutes a  valuable  symptom  in  prognosis,  as  in  muscles  which  are  com- 
pletely paralyzed  faradic  irritability  is  permanently  lost  by  the  second 
iceek.  But  even  in  later  years  it  may  be  possible  to  find  in  such  muscles 
a  trace  of  irritability  to  the  faradic  current  by  thrusting  a  hypodermic 
needle  into  the  muscular  substance  and  transmitting  the  current  through 
30 


±66  ORTHOPEDIC    SURGERY. 

that.  But  the  change  in  reaction  to  the  galvanic  current  is  even  more 
important.  Normally  when  this  current  is  passed  through  nerve  and 
muscle,  a  quick  sharp  muscular  contraction  takes  place  at  the  opening 
and  closing  of  the  current  and  the  muscular  contraction  should  be  greater 
at  the  closing  of  the  negative  pole  than  when  the  positive  pole  is  closed. 
The  cathodal  closing  contraction  should  be  normally  greater  than  the 
anodal  closing  contraction.  When  nerves  and  muscles  affected  by  anterior 
poliomyelitis  are  examined,  not  only  a  slow  wave-like  response  to  electricity 
instead  of  a  sharp  quick  jerk  is  found,  but  the  electrical  formula  is  re- 
versed and  the  closure  of  the  positive  pole  gives  the  greater  contraction.  In 
general  a  much  stronger  galvanic  current  is  needed  to  produce  a  contrac- 
tion in  these  paralyzed  muscles  than  in  normal  ones.  These  qualitative 
and  quantitative  changes  in  reaction  to  the  galvanic  current  constitute 
what  is  known  as  the  "  reaction  of  degeneration, "  and  this  affords  the 
most  definite  ground  for  the  diagnosis  of  infantile  paralysis.  But  such 
an  examination  to  be  of  any  value  requires  practice  and  special  skill  in 
the  use  of  electricity.  In  young  children  the  examination  often  yields 
no  results  even  to  a  specialist  in  nervous  diseases  on  account  of  the 
child's  constant  activity,  and  although  it  is  the  most  definite  means  of 
diagnosis  that  we  possess  in  obscure  cases,  its  use  is  attended  with  many 
difficulties. 

The  only  affection  which  may  not  be  distinguished  by  electrical  exam- 
ination from  anterior  poliomyelitis  is  peripheral  paralysis  caused  by  in- 
terruption in  the  course  of  some  nerve. 

Differential  Diagnosis. 

The  leading  points  which  are  to  be  depended  upon  in  the  differential 
diagnosis  are  these :  Infantile  paralysis  is  purely  a  motor  affection  and 
sensation  is  never  permanently  impaired.  The  reflexes  are  generally 
diminished  or  lost.  Wasting  is  rapid  and  extreme  and  the  leg  is  cold 
and  blue  in  severe  cases.  The  "  reaction  of  degeneration  "  is  present  in 
electrical  examination. 

Cerebral  paralysis  generally  begins  with  a  sudden  onset,  and  often 
convulsions  are  present  and  the  child  is  found  to  have  lost  the  use  of  one 
side  of  the  body.  It  differs  from  infantile  paralysis  in  these  points :  Its 
distribution  is  hemiplegic  and  facial  paralysis  is  common,  the  tendon  re- 
flexes are  increased  from  first  to  last,  faradic  excitability  is  not  lost,  and 
the  galvanic  formula  is  normal ;  later  the  intelligence  is  generally  affected 
and  atrophy  is  neither  so  marked  nor  so  rapid  as  in  infantile  spinal 
paralysis,  but  similar  contractions  of  the  joints  of  the  affected  limb  come 
on.  These  contractions  are,  however,  often  spastic  in  character.  Allu- 
sion must  be  made  to  the  importance  of  electricity  in  making  a  differen- 
tial diagnosis,  which  is  often  attended  with  much  difficulty.     A  hemi- 


INFANTILE   SPINAL   PARALYSIS. 


467 


plegic  distribution  of  infantile  spinal  paralysis  is  rare, '  but  cases  have 
been  reported  in  which  the  facial  nerve  was  involved.2 


Tablk    ok    the    Differential    Diagnosis    ov    Infantile    Paralysis 
and   Cerebral    Paralysis. 


Age. 

Onset. 

IMstri  b  u  ti  o  n    o  I: 
paralysis. 

Reflexes. 
Electrical  reaction. 


Mental     i  in  pa  i  r 
ment. 


Infantile  Spinal  Paralysis. 

Sharply  limited  to  children  in 
first  dentition. 

Sudden,  but  severe  convulsions 
not  often  present. 

Oftenest  monoplegia  or  para- 
plegia ;  rarely  involves  facial 
nerve- 
Lost  generally. 

Faradism,  diminished  or  lost. 

Galvanism,  formula  reversed 
(reaction  of  degeneration) . 

Absent. 

Spastic  condition  absent. 


cerebral  Paralysis  (Hemiplegia). 

Not  sharply  limited  to  young 
children. 

Sudden,  and  severe  convulsions 
generally  present. 

Hemiplegia ;  generally  involv- 
ing facial  muscles  on  one 
side. 

Increased. 

Faradism,  normal. 

Galvanism,  normal. 

Likely  to  come  on. 

Spastic  condition  of  one  or 
both  legs  often  follows. 

Both  affections  are  characterized  by  motor  paralysis,  wasting  and 
retarded  growth  of  the  affected  limb,  and  contractions  of  the  joints. 

Progressive  muscular  atrophy  in  childhood  is  a  very  rare  affection,  but 
it  has  been  observed,  sometimes  beginning  in  the  legs.  Its  onset  is  grad- 
ual, and  the  faradic  excitability  remains  so  long  as  there  is  any  muscular 
substance  left  and  the  galvanic  formula  remains  normal.  The  reflexes 
are  not  lost  until  all  muscular  substance  has  gone. 

Acute  transverse  myelitis  of  the  dorsal  region  causes  paralysis  of  the 
legs  when  it  occurs,  but  unless  the  lumbar  enlargement  is  involved  there 
is  no  loss  of  electrical  irritability.  Reflex  action  after  a  day  or  two  is 
much  increased  and  ankle  clonus  can  be  obtained.  There  is  generally 
paralysis  of  sensation,  and  bed-sores  develop  with  much  rapidity,  while 
any  wasting  is  very  gradual.  There  is  no  change  in  the  electrical 
formula. 

A  paralysis  much  like  that  in  anterior  poliomyelitis  has  been  de- 
scribed by  Bullard  following  cerebrospinal  meningitis.  In  such  cases 
pain  and  tenderness  of  muscles  persist  longer  than  in  infantile  paralysis. 
There  is  a  tendency  to  spastic  contraction  in  the  early  stages  which  be- 
comes less  later.  The  knee  jerks  on  the  whole  are  less  affected  than  in 
infantile  paralysis ;  they  may,  however,  be  absent  entirely. 3 

Diphtheritic  paralysis  may  offer  serious  difficulty  in  diagnosis,  because 

1  Duchenne  and  Seeligmiiller  (3  cases),  Sinkler  (4),  West  (5),  Heine  (1),  Leyden 
(1),  Duchenne  (1). 

2 Henoch:  Loc.  cit.,  p.  203;  Barlow:  Loc.  cit.,  p.  76;  Seeligmiiller. 
3 Boston  Med.  and  Surg.  Journ.,  vol.  i..  p.  159,  1899. 


4(>8  ORTHOPEDIC   SURGERY. 

anterior  poliomyelitis  may  occur  in  the  course  of  a  diphtheritic  attack  as 
in  any  other  infectious  disease.  The  paralysis  of  diphtheria  affects  often- 
est  the  muscles  of  the  palate  and  fauces,  the  electrical  reactions  remain 
normal,  and  severe  atrophy  is  not  present. 

Pseudo-Itypertrbphic  paralysis  in  its  early  stages  is  not  likely  to  be 
confused  with  infantile  paralysis,  for  it  is  generally  characterized  by 
much  increase  in  the  size  of  the  muscles,  which  is  extensively  distributed 
and  comes  on  very  gradually  and  is  not  accompanied  by  any  marked  elec- 
trical changes.  Late  in  the  affection  marked  muscular  atrophy  occurs, 
but  it  is  generalized  and  the  history  would  clearly  differentiate  the  con- 
dition from  anterior  poliomyelitis. 

Paralysis  may  result  from  lesion  of  a  peripheral  nerve,  as  in  instru- 
mental delivery  at  childbirth,  from  tight  bandaging,  etc.  But  its  dis- 
tribution is  limited  to  a  single  nerve  or  group  of  nerves  and  it  is  charac- 
terized by  a  concomitant  affection  of  sensibility.  The  electrical  reaction 
would  be  the  same  as  in  infantile  paralysis. 

The  so-called  rhachitic  paralysis  might  offer  some  difficulty  of  diag- 
nosis. But  it  occurs  in  the  acute  stage  of  rickets  and  is  not  a  paralysis 
so  much  as  a  disinclination  to  use  weak  and  tender  limbs.  It  is  accom- 
panied by  general  tenderness  and  to  a  certain  extent  by  the  diagnostic  signs 
of  rickets,  the  reflexes  are  normal  and  its  onset  is  more  gradual.  It  is, 
however,  so  early  a  complication  of  rickets  that  its  recognition  may  offer 
difficulty. 

Practically  infantile  paralysis  of  one  leg  sometimes  simulates  at  first 
slight  congenital  dislocation  of  the  hip,  but  only  inattention  can  account 
for  a  mistake  in  the  diagnosis.  In  congenital  dislocation  the  trochanter 
would  be  above  Nelaton's  line,  it  would  yield  to  traction,  atrophy  would 
be  very  slight,  and  the  electrical  reaction  normal. 

With  hip  disease,  infantile  paralysis  is  at  times  confounded  in  prac- 
tice. The  onset  of  the  paralysis  may  be  accompanied  by  joint  pain  and 
tenderness,  and  on  the  other  hand  hip  disease  is  accompanied  by  serious . 
muscular  atrophy  and  a  modification  of  faradic  irritability  of  the  muscles, 
as  Shaffer1  has  shown.  But  the  distinguishing  feature  of  hip  disease  is 
muscular  fixation,  and  that  is  not  present  in  infantile  paralysis,  in  which 
muscular  laxity  is  the  prevailing  condition.  The  onset  of  hip  disease, 
although  generally  gradual,  may  at  times  be  apparently  sudden. 

Prognosis. 

So  far  as  danger  to  life  is  concerned,  the  outlook  in  infantile  paralysis 
is  very  favorable,  for  few  patients  die  in  the  acute  attack.  When  death 
does  occur  it  is  generally  at  the  end  of  a  week  or  ten  days.  Continued 
cerebral  symptoms,  however,  are  of  grave  significance.     In  cases  in  which 

1  N.  M.  Shaffer:  Archives  of  Medicine,  New  York. 


INFANTILE   SPINAL   PARALYSIS.  469 

the  deformity  is  only  of  moderate  extent,  it  is  not  probable  that  life  will 
be  shortened  by  it. 

It  is  not  likely  that  the  paralysis  will  increase  any  more  when  it  has 
been  stationary  for  twenty -four  hours.  Second  attacks  are  very  rare,  and 
when  they  do  occur,  they  come  on  within  a  day  or  two  of  the  original 
attack  and  are  made  evident  by  an  increase  of  the  existing  paralysis. 

The  tendency  of  the  paralysis,  as  we  have  seen,  is  toward  improve- 
ment and  partial  recovery.  The  law  of  Duchenne  gives  the  keynote  to 
a  more  exact  prognosis  in  establishing  the  fact  that  all  the  paralyzed 
muscles  in  which  the  faradic  irritability  is  only  more  or  less  diminished, 
but  not  completely  lost,  during  the  course  of  the  second  week,  do  not 
remain  permanently  paralyzed,  the  restoration  being  more  prompt  and 
complete  the  less  the  faradic  irritability  has  been  diminished.  In  gen- 
eral when  the  faradic  irritability  is  lost  at  once,  paralysis  will  be  severe 
and  to  a  certain  extent  permanent.  When  the  irritability  is  lost  later, 
the  paralyzed  muscles  will  improve  slowly  and  nearly  recover.  When 
faradic  irritability  is  not  lost  at  all,  recovery  will  take  place  in  a  few 
weeks  or  months.  Without  the  use  of  electricity  one  has  to  wait  much 
longer  before  giving  any  more  definite  prognosis  than  a  general  promise 
of  improvement. 

When  untreated,  a  case  of  infantile  paralysis  will  almost  invariably 
improve  for  one  or  two  months  at  a  rapid  rate,  then  more  slowly  for  two 
or  three  months  more,  and  then  after  a  stationary  period,  contractions, 
looseness  of  the  joints,  and  malpositions  are  likely  to  begin,  which  may 
increase  indefinitely.  Under  treatment  the  prognosis  is  much  more 
favorable  and  the  limit  of  possible  improvement  extended  by  many  years. 
There  is  scarcely  any  leg,  however  wasted  and  contracted,  that  is  not 
amenable  to  improvement  by  operative  or  mechanical  treatment. 

It  should  be  remembered  that  even  in  mild  cases  of  infantile  paralysis 
bone  shortening  is  liable  to  follow.  It  is  very  variable  atrophy,  and 
certain  severe  cases  escape  with  but  little,  while  a  mild  case  of  talipes 
valgus  may  show,  with  the  wasting  of  the  leg,  a  shortening  of  one  or  two 
inches  in  the  limb  of  the  affected  side,  or  in  exceptionally  severe  cases, 
shortening  of  several  inches. 

Treatment. 

The  treatment  of  infantile  paralysis  varies  according  to  the  stage  at 
which  treatment  is  to  be  undertaken. 

The  Stage  of  Onset. — If  the  fact  that  paralysis  is  present  is  estab- 
lished during  the  febrile  attack,  which  is  usually  the  first  symptom  of 
the  disease,  vigorous  treatment  should  be  at  once  begun,  to  limit,  if  pos- 
sible, the  destructive  process  in  the  cord.  Cathartics  should  be  given  at 
once,  the  patient  should  lie  on  the  side  or  the  belly,  to  prevent  stasis  of 


470  ORTHOPEDIC   SURGERY. 

the  blood  in  the  spinal  cord,  and  counter-irritants  or  cups  should  be  ap- 
plied over  the  spine.  Ergot  should  be  administered  in  doses  of  ten 
drops  of  the  fluid  extract,  three  times  a  day,  for  infants  of  six  months, 
and  half  a  drachm  for  children  of  one  or  two  years.  Bromide  of  potas- 
sium and  of  sodium  are  recommended  on  the  ground  that  they  contract 
the  capillaries  of  the  spinal  cord.  The  general  condition  of  the  child 
should  in  every  way  be  kept  as  good  as  possible.  Antipyretics  may  be 
indicated. 

The  Stage  of  Paralysis. — But  few  cases  are  seen  by  the  surgeon  until 
the  stage  of  paralysis  is  present,  when  treatment  by  medicine  is  mani- 
festly of  little  avail.  The  question  that  then  presents  itself  is  in  regard 
to  the  treatment  of  the  paralysis,  in  order  that  the  ultimate  amount  of 
muscular  power  may  be  as  great  as  possible.  It  must  be  remembered 
that  the  tendency  of  the  paralysis  is  at  first  very  strong  toward  sponta- 
neous improvement.  It  is  therefore  manifest  that  in  the  first  few 
weeks  treatment  should  be  directed  toward  producing  conditions  which 
shall  be  as  favorable  as  possible  for  that  improvement  to  attain  its  maxi- 
mum. 

The  object  of  treatment  in  this  stage  should  therefore  be  first  to  sup- 
port the  affected  limb  in  a  normal  position,  and  most  carefully  guard 
against  the  stretching  of  joints  and  ligaments  and  muscles;  and,  secondly, 
by  the  use  of  electricity,  massage,  and  systematic  exercise  to  keep  the 
nutrition  of  the  affected  muscles  in  the  best  possible  condition.  In  this 
way  only,  by  beginning  the  treatment  at  the  first,  can  the  best  possible 
ultimate  result  be  obtained. 

It  has  been  seen  that  what  may  be  called  protective  treatment  should 
be  begun  at  once,  and  from  the  first  the  diseased  limb  should  be  placed 
and  retained  in  a  normal  position,  so  that  the  affected  muscles  and  joints 
may  be  supported  and  kept  at  rest.  In  this  way  the  enfeebled  muscles 
are  placed  under  the  best  possible  conditions  for  their  recovery.  To 
allow  attention  to  be  diverted  from  these  very  important  measures  to 
pursue  a  medical  treatment  whose  utility  is  doubtful,  is  manifestly  irra- 
tional. In  paralysis  of  the  legs  the  feet  should  be  supported  from  the 
first  at  a  right  angle,  in  their  normal  position,  by  some  simple  splint  or 
similar  appliance,  and  the  weight  of  the  bed  clothes  should  be  kept  off  of 
the  toes. 

The  appliances  needed  to  maintain  in  a  proper  position  the  limbs  of  a 
patient  with  paralysis  will  vary  according  to  the  parts  affected  and  will 
demand  some  ingenuity  on  the  part  of  the  surgeon.  In  severe  and  exten- 
sive cases  light  bed  frames  may  be  very  useful  to  allow  the  patient  to  be 
carried  about,  while  retaining  the  limbs  in  a  proper  position.  So  far  as 
possible  in  such  cases  bandages  should  be  avoided,  and  straps  should  be 
used  instead,  as  the  surface  circulation  is  feeble  and  likely  to  be  impeded 
by  bandages. 


INFANTILE   SPINAL    PARALYSIS.  471 

When  the  arm  is  paralyzed,  a  sling  should  be  worn  to  prevent  drag- 
ging of  the  arm  upon  the  shoulder-joint  ligaments  and  the  weakened  del- 
toid muscle. 

Electricity  is  a  most  useful  therapeutic  measure  in  the  early  stage  of 
the  paralysis.  Treatment  should  be  begun  as  early  as  the  spinal  irrita- 
tion seems  to  have  disappeared,  probably  about  the  end  of  the  first  week, 
and  continued  indefinitely,  but  not  to  the  exclusion  of  proper  mechanical 
treatment.  The  galvanic  current  is  used,  a  very  gentle  current  is  passed 
through  the  affected  muscles  and  nerves  for  a  few  minutes  each  day, 
and  muscles  which  contract  only  feebly  to  faradism  should  be  daily  stim- 
ulated by  the  application  of  the  faradic  current.  Muscles  which  will 
not  contract  to  faradism  can  sometimes  be  much  improved  by  applica- 
tions of  the  interrupted  galvanic  current.  The  chief  use  of  electricity, 
it  is  to  be  remembered,  is  to  stimulate  to  contraction  the  paralyzed 
muscles,  thereby  affording  a  sort  of  gymnastics.  Probably  electrical 
treatment  receives  much  credit  in  the  treatment  of  this  disease,  which 
is  not  properly  due  to  it,  for  it  is  employed  at  a  time  when  marked 
improvement  is  almost  certain,  and  very  much  the  same  results  can  be 
obtained  by  methods  about  to  be  considered.  One  sees  cases  in  which  it 
lias  ceased  to  benefit  the  child  and  has  been  persisted  in  to  the  exclusion 
of  more  rational  treatment  for  that  especial  case.  But  even  in  the  late 
stages  of  the  disease,  when  wasting  and  deformity  have  come  on,  the  use 
of  electricity  may  at  times  lead  to  an  improvement  of  nutrition. 

Dry  warmth  and  rubbing  are  measures  which  seem  of  ecpial,  if  not  of 
greater,  value  in  the  stage  of  simple  paralysis.  Heat  is  easily  applied  by 
having  the  child  sit  in  front  of  a  fire  or  stove  with  the  leg  thrust  through 
a  hole  in  a  sheet  of  pasteboard.  This  serves  as  a  screen  to  the  rest  of 
the  body,  while  the  affected  member  is  allowed  to  become  thoroughly 
warmed  once  or  twice  a  day  either  in  this  way  or  by  a  hot-air  oven.  Dur- 
ing the  day,  especially  in  cold  weather,  the  paralyzed  limb  should  be  pro- 
tected by  two  thick  stockings  and  a  warm  boot.  Any  treatment  which 
stimulates  the  circulation  of  the  paralyzed  limb  aids  in  its  recovery  by 
improving  the  nutrition  of  the  muscles,  and  dry  heat  very  effectually 
accomplishes  this  end.  A  paralyzed  leg  should  be  thoroughly  heated  for 
an  hour  before  it  is  rubbed  at  night.  ♦ 

Massage  is  another  most  important  element  of  treatment  in  this  as  in 
any  stage  of  infantile  paralysis  after  the  initial  irritation  has  quieted 
down.  Skilled  massage,  when  it  can  be  obtained,  is  of  course  better  than 
friction  at  the  hands  of  the  parents,  bnt  the  latter  is  a  simple  and  effi- 
cient treatment,  which  lies  within  the  reach  of  most  people. 

In  the  place  of  the  usual  manual  massage,  mechanical  massage  of  the 
limbs  has  been  employed  by  means  of  carefully  constructed  appliances. 
This,  however,  will  be  within  the  reach  of  but  few. 

Active  muscular  exercise  of  the  paralyzed  limb  is  a  most  desirable 


472  ORTHOPEDIC    SURGERY. 

tonic  to  the  affected  muscles,  however  it  is  obtained,  provided  the  mus- 
cles be  not  overtaxed.  With  the  assistance  of  the  parent's  hand,  a  foot 
which  naturally  drops  forward  from  paralysis  of  the  anterior  leg  muscles 
can  be  flexed,  and  with  each  repetition  of  the  exercise  the  muscle  will  be 
found  able  to  accomplish  more.  It  is  impossible  to  lay  down  any  series 
of  exercises.  In  each  case  the  problem  must  be  met  differently.  The 
aim  should  be  so  to  assist  the  affected  muscles  that  if  they  have  any 
power  left  they  may  be  enabled  to  use  it  daily  for  their  own  advantage. 
And  with  this  in  view,  assistance  should  be  rendered  by  supporting  and 
aiding  the  affected  limb  in  its  movements  in  the  way  most  likely  to  call 
into  use  these  paralyzed  muscles.  Such  exercise  forms  a  most  useful 
adjunct  to  the  massage.  It  should  be  repeated  each  night  just  before  or 
just  after  the  massage. 

H.  L.  Taylor,  in  an  excellent  paper  on  the  hygiene  of  reflex  action, 
says :  "  In  the  neuromuscular  degenerations  following  acute  anterior 
poliomyelitis,  it  is  especially  important  to  restore  to  the  paretic  extremi- 
ties, so  far  as  possible,  the  stimuli  of  locomotion  and  other  normal  asso- 
ciated movements  without  the  inhibition  of  insecure  footing  and  strained 
tissues — and  it  is  for  the  specific  purpose  of  restoring  to  the  damaged 
cord  and  muscles  the  cutaneous,  muscular,  and  articular  stimuli  of  loco- 
motion that  apparatus  is  constructed. 

"  Normal  reflexes  of  locomotion  are  broken  up,  and  a  wasteful  and 
cumbersome  set  installed,  subject  to  constant  cerebral  interference  in  the 
efforts  at  balancing  and  progression,  and  additionally  disturbed  by  the 
strain  in  weakened  muscular  and  joint  structures  which  is  rendered  inev- 
itable by  the  lack  of  balance  between  opposing  groups.  Mechanical  pro- 
tection with  muscular  training  enables  the  patient  to  acquire  a  better  set 
of  reflexes  and  promotes  the  nutrition  of  the  part." 

Mechanical  Treatment. 

The  mechanical  treatment  of  this  disease  often  presents  a  most  diffi- 
cult problem.  Absolute  accuracy  in  the  fitting  of  the  apparatus  is  an 
essential,  and  the  varying  indications  make  necessary  constant  modifica- 
tions in  the  appliances  to  be  used. 

The  mechanical  treatmeut  of  infantile  paralysis  is  twofold  in  its 
object.  The  first  and  simplest  use  of  apparatus  is  to  support  and  protect 
the  paralyzed  limb  in  such  a  way  that  the  muscles  shall  work  to  the  best 
advantage  and  that  the  joints  may  be  supported  and  controlled.  By 
doing  this  the  occurrence  of  contraction  deformities  is  prevented  and  the 
nutrition  of  the  limb  is  kept  in  the  best  possible  condition  by  enabling 
the  limb  to  be  used  in  a  comparatively  normal  way. 

The  second  function  of  mechanical  treatment  in  infantile  paralysis  is 
to  overcome  by  means  of    suitable  appliances    deformities  which  have 


INFANTILE    SPINAL  PARALYSIS.  47H 

already  occurred  and  to  prevent  their  recurrence;  it  may  often  be  neces- 
sary to  attempt  both  objects  with  one  apparatus. 

The  Indications  for  Mechanical  Treatment. — Whenever  a  paralyzed 
limb  is  unable  to  bear  the  weight  of  the  body  which  falls  upon  it  in  loco- 
motion, some  mechanical  help  is  manifestly  advisable.  This  is  not  only 
needed  when  the  paralysis  is  complete,  but  also  when,  owing  to  incom- 
plete muscular  strength,  more  strain  is  borne  on  the  articular  ligaments 
than  is  normal.  Moreover,  when  the  bearing  of  the  body  weight  or  the 
act  of  walking  throws  the  foot  or  the  leg  into  any  abnormal  position,  the 
use  of  some  appliance  is  indicated.  It  is  difficult  to  describe  the  various 
appliances  needed  in  the  treatment  of  infantile  paralysis,  and  much  must 
be  left  to  the  ingenuity  of  the  surgeon  in  each  case. 

The  first  division  of  the  mechanical  treatment  of  these  cases  con- 
sists in  furnishing  sufficient  support  to  the  limb  in  the  following  con- 
ditions :  * 

1st.   Paralysis  of  the  muscles  of  the  legs  and  feet. 

2d.   Paralysis  of  the  muscles  of  the  thigh. 

3d.   Paralysis  of  the  muscles  of  the  back. 

And  a  combination  of  these  various  paralyses. 

Paralysis  of  the  Leg.  —  When  the  muscles  of  the  leg  are  paralyzed, 
those  which  help  to  control  the  ankle-joint  in  standing  and  walking  are 
rendered  inefficient  and  the  ligaments  may  become  relaxed  so  that  in  the 
standing  position  the  ankle  of  the  affected  side  cannot  sustain  the  body 
weight  as  it  should,  and  the  foot  is  apt  to  roll  in  or  out,  causing  an  inver- 
sion or  eversion  of  the  foot  amounting  to  a  degree  of  talipes  varus  or 
valgus. 

In  any  apparatus  which  is  to  sustain  the  foot  in  its  weight-bearing 
function,  accuracy  of  support  is  indispensable,  and  a  simple  leathor  boot, 
however  stout  it  may  be,  soon  yields  and  the  foot  slips  away  from  the 
rest  of  the  apparatus,  and  the  efficiency  of  the  brace  is  impaired ;  a  rigid 
sole  is,  therefore,  essential  for  any  apparatus  which  is  to  control  the 
ankle  properly,  and  this  can  easily  be  accomplished  by  having  a  thin 
steel  plate  inserted  between  the  layers  of  the  sole  of  the  boot. 

When  no  contraction  or  deformity  exists  at  the  ankle,  but  there  is 
simply  a  tendency  of  the  front  of  the  foot  to  drop  on  account  of  the  affec- 
tion of  the  anterior  muscles  of  the  leg,  locomotion  can  be  made  much 
more  easy  by  preventing  this.  A  common  appliance  for  this  latter  de- 
formity is  an  ordinary  shoe  fitted  with  lateral  steel  uprights  and  a  pos- 
terior steel  calf  band.  There  is  a  right-angle  stop  catch  at  the  ankle 
which  keeps  the  foot  from  being  fully  extended. 

The  same  end  can  be  better  accomplished  by  the  application  of  a  walk- 
ing appliance,  described  under  club-foot  as  a  varus  shoe,  which  should  be 
provided  with  a  right-angle  stop  at  the  ankle  which  will  not  allow  the 
ankle  to  be  extended  to  more  than  a  right  angle.     When  in  bearing  weight 


474 


ORTHOPEDIC    SURGERY. 


upon  the  leg  the  ankle  assumes  a  varus  position,  the  same  varus  shoe 
will  correct  the  tendency  to  deformity. 

If  the  foot  rolls  out  and  is  everted  into  a  valgus  condition  when  the 
body  weight  is  borne  upon  the  leg,  an  outside  shoe  is  to  be  applied,  in 
construction  like  the  varus  shoe,  but  which  should  have  a  broad  leather 
strap  which  should  pass  around  the  inner  malleolus  and  support  it.  This 
apparatus  is  a  difficult  one  to  render  quite  comfortable  to  the  patient,  as 
much  weight  must  necessarily  come  upon  the  strap  which  supports  the 


Fig.  446.  Fig.  447. 

Figs.  44(1  and  447.— Splint  with  Single  Upright  for  Infantile  Paralysis  of  Right  Leg  with  Varus  Deformity 
of  Ankle  ;  unapplied  and  applied. 


inner  malleolus.  As  flat-foot  is  almost  always  present  in  these  cases,  it 
is  well  to  arch  the  steel  sole  plate  of  this  apparatus  so  that  it  serves  as  a 
valgus  plate  as  well  as  a  supporting  appliance. 

It  is  manifest  that  the  simpler  and  lighter  these  appliances  are  and 
the  less  unsightly,  the  more  serviceable  they  will  prove.  For  this  reason 
they  should  be  carefully  fitted  and  the  uprights  made  to  follow  the  out- 
line of  the  leg.  In  very  slight  cases,  in  which  there  is  only  a  slight  ever- 
sion  of  the  foot  with  a  small  degree  of  valgus,  a  common  valgus  plate, 
such  as  would  be  applied  for  flat-foot,  will  often  answer  every  purpose  in 
correcting  the  deformity,  and  it  should  be  applied  as  in  simple  flat-foot. 

In  severe  cases  of  paralysis  of  the  muscles  of  the  legs  and  foot,  the 
thigh  muscles  may  be  involved.     The  same  appliance  will  often  have  to 


INFANTILE    SPINAL    PARALYSIS. 


475 


support  the  knee  and  thigh  as  well  as  to  correct  deformity  at  the  ankle. 
But  this  involves  merely  an  extension  of  the  apparatus  up  the  leg. 

Paralysis  of  the  Thigh  Muscles. — When  the  muscles  of  the  thigh  are 
involved  in  the  paralysis,  the  limb  becomes  unable  to  sustain  the  weight 
thrown  upon  it  and  the  knee  flexes  and  the  limb  drops  forward  when 
weight  is  borne  upon  it.  The  knee-joint  does  not  bend  to  one  side  or  the 
other,  as  the  lateral  ligaments  retain  much  strength.  In  a  few  instances 
the  knee  will  drop  backward  to  more  than  a  straight  line,  but  owing  to 
the  strength  of  the  crucial  ligaments  in  infantile  paralysis  it  never  falls 
so  far  back  as  to  be  unable  to  sustain  weight.     For  the  practical  purposes 


Fig.  448.  Fig.  449. 

Figs.  448  and  449.— Supporting  Apparatus  in  Paralysis  of  Anterior  Thigh  Muscles. 

of  locomotion,  therefore,  it  is  only  essential  that  the  knee  be  prevented 
from  dropping  forward,  and  this  can  be  done  by  means  of  any  appliance 
which  will  press  the  knee  backward.  The  simplest  way  of  doing  this 
is  by  the  use  of  two  steel  rods  reaching  from  the  back  of  the  thigh  to  the 
bottom  of  the  shoe.  These  rods  are  placed  on  the  outer  and  inner  side 
of  the  limb  and  are  connected  at  the  top  by  a  posterior  steel  band,  which 
furnishes  a  counterpoint  of  pressure  by  which  to  hold  the  knee.  If  a 
strap  is  passed  in  front  of  the  knee,  it  is  impossible  for  it  to  drop  for- 
ward when  weight  is  thrown  upon  the  leg,  and  the  patient  can  stand 
upon  the  limb.  The  appliance  supplies  the  check  normally  exercised  by 
the  muscles.  Below  it  should  be  fitted  to  a  boot,  or  if  the  muscles  of  the 
leg  are  also  involved,  to  one  of  the  appliances  such  as  the  varus  or  valgus 
shoe  mentioned  above.  The  principle  of  such  apparatus  in  retaining  the 
knee  extended  is  shown  in  Pigs.  448  and  449. 


476 


ORTHOPEDIC   SURGERY. 


Instead  of  being  applied  by  means  of  a  steel  sole  plate,  the  apparatus 
may  be  fastened  to  the  sole  of  the  boot.  In  addition  to  the  bands  shown 
in  the  figure,  leather  lacings  to  retain  the  thigh  and  calf  will  probably  be 
needed  to  give  the  apparatus  greater  stability,  as  the  lacings,  by  covering 


o 


Fig,  450.  Fig.  451. 

Figs.  450  and  451.— Supporting  Apparatus  for  Infantile  Paralysis  of  Leg  and  Thigh,  with  Knee-cap. 

a  large  area  of  skin,  substitute  surface  pressure  for  the  point  pressure 
given  by  narrow  straps.  This  is  a  matter  to  be  considered  in  all  sup- 
porting apparatus. 

If  the  knee  tends  to  drop  backward  and  become  hyperextended,  it 
can  be  remedied  by  a  similar  appliance  with  a  strap  passing  behind  the 
knee,  with  an  upper  band  encircling  the  thigh.  In  practice  this  apparatus 
can  often  consist  of  a  single  outside  upright  hinged  at  the  knee.  It 
passes  to  the  inside  of  the  leg  just  below  the  knee  to  become  attached  to 


INFANTILE   SPINAL   PARALYSIS. 


477 


a  varus  shoe.  This  answers  as  well  as  a  double  upright  in  many  cases. 
The  apparatus  can  be  hinged  at  the  knee  for  convenience  in  sitting  down 
and  should  be  furnished  with  leather  lacings  for  the  thigh  and  calf  (see 
Figs.  446  and  447.) 

Other  cases,  in  which  the  paralysis  is  more  severe,  require  the  two  up- 
rights, as  they  furnish  a  more  definite  support.  The  foot  is  easily  re- 
tained to  the  steel  sole  plate  by  straps  or  a  piece  of  leather  lacing  over 
the  instep.  The  fenestrated  knee  cap  is  the  most  comfortable  method  of 
holding  the  knee  extended  (Figs.  450  and  451). 

Although  in  walking  it  is  generally  necessary  to  have  the  knee  kept 
extended  by  the  splint,  yet  in  sitting  down  it  is  a  great  comfort  to  the 


Fig.  452.  —  Drop-catch. 


Fig.  453.  Fig.  454. 

Figs.  453  and  454.— Self-locking  Spring-catch. 


patient  to  be  able  to  flex  the  knee,  and  for  this  reason  nearly  all  splints 
should  be  hinged  at  the  knee. 

A  great  variety  of  hinges  can  be  applied  at  the  knee  with  different 
catches,  enabling  the  patient  to  bend  the  limb  by  loosening  the  catch  or 
locking  it  when  it  is  desired  that  the  limb  should  be  stiff.  The  simplest 
and  most  economical  of  these  is  the  simple  drop  catch  shown  in  the 
figure.  When  the  limb  is  straightened,  the  ring  falls  down  and  locks 
the  splint  in  the  extended  position,  but  it  can  be  pulled  up  at  any  time, 
allowing  the  knee  to  bend. 

In  another  and  more  expensive  form  the  splint  is  self -locking,  and  the 
bending  is  made  possible  by  pressing  a  handle  at  the  outside  of  the  knee. 

When  the  adductor  muscles   are   affected,   little  or  nothing  can  be 


478 


OKTHOPEDIC    SURGERY. 


done  to  supplement  them  by  mechanical  means  without  employing  heavy 
apparatus,  inasmuch  as  their  loss  of  power  occurs  only  in  extensive 
paralysis.  This  can  be  done  by  encircling  the  pelvis  by  a  stout  leather 
band  which  is  connected  with  the  leg  appliance  by  joints  at  the  hip. 
The  appliance  shown  in  Fig.  456  is  a  useful  form  of  this  sort  of  appa- 
ratus, and  even  in  very  extensive  paralysis  of  both  legs  it  may  furnish 
much  support.  Little  can  be  done  to  remedy  paralysis  of  the  glutei 
muscles,  but  when  paralysis  of  the  legs  appears  to  be  complete,  a  certain 


Fig.  455.— Mechanism  for  Locking   Knee-joint. 
(H.  L.  Taylor.) 


Fig.  456. 


-Burrell's  Splint  for  Complete  Infantile 
Paralysis  of  Both  Legs. 


amount  of  relief  may  be  given  by  attaching  the  leg  uprights  to  a  leather 
or  silicate  jacket.  The  common  Thomas  knee  splint  may  be  joined  to 
a  leather  jacket  by  lateral  uprights  jointed  at  the  trochanters. 

The  muscles  of  the  back  are  rarely  if  ever  paralyzed,  except  in  con- 
nection with  palsy  of  some  of  the  muscles  of  the  leg.  Complete  paralysis 
of  the  muscles  of  the  trunk  indicates  an  extent  of  disease  which  is  most 
distressing.  When  the  muscles  of  the  back  are  but  partially  affected, 
help  may  be  afforded  by  the  use  of  corsets  or  other  supporting  appli- 
ances, such  as  are  employed  in  the  deformities  of  the  spine.  These  can 
be  connected  with  the  leg  appliances  and  will  afford  assistance  in  stand- 
ing.    Cases  of  this  sort  may  be  so  severe  as  to  require  the  use  of  crutches 


INFANTILE    SPINAL    PARALYSIS.  479 

for  rapid  locomotion,  but  much  assistance  may  be  afforded  by  appliances 
in  many  cases. 

The  abdominal  muscles  are  sometimes,  though  rarely,  affected,  giving 
a  protuberant  abdomen,  and  a  position  of  much  lordosis  in  standing. 
Waist  bands  or  corsets  will  serve  to  correct  the  appearance  of  the  trunk 
to  a  certain  extent. 

The  mechanical  treatment  of  infantile  paralysis  of  the  arm  is  not  a 
question  which  arises  often  enough  to  make  it  worth  while  to  enter  upon 
any  discussion  of  it,  save  to  mention  that  the  principles  of  treatment  arc 
the  same  as  those  already  considered. 

The  use  of  elastic  bands  to  supply  the  place  of  the  disabled  muscles 
is  thought  in  some  instances  to  be  sufficient  to  compensate  for  the  action 
of  the  paralyzed  muscles.  It  will,  however,  be  found  that  an  elastic 
support,  inasmuch  as  it  is  not  of  certain  tension",  is  necessarily  a  varying 
support  'and  adds  to  the  complicated  nature  of  the  appliance  rather  than 
to  its  efficiency,  nor  is  it  possible  to  gauge  accurately  the  force  or  press- 
ure exerted  at  any  time.  It  is  generally,  therefore,  a  much  less  effi- 
cient form  of  apparatus  than  the  rigid  forms  here  advocated. 

Mechanical  Treatment  as  Applied  to  the  Correction  of  the  Deformity. 
— Whether  the  deformity  shall  be  corrected  by  purely  mechanical  means 
or  by  operative  interference  depends  not  only  upon  the  nature  of  the  dis- 
tortion, but  also  upon  the  time  at  the  disposal  of  the  patient  and  surgeon. 
Many  of  the  distortions  of  this  sort  can  be  cured  in  children  without  any 
operative  interference,  as  all  that  is  required  is  the  stretching  of  the 
fasciae  and  the  contracted  tendons.  These  distortions  are  either  flexions 
at  the  hip  or  knee  or  some  distortion  of  the  ankle.  The  less  severe  of 
these  distortions  yield  readily  upon  the  application  of  efficient  force. 

Deformity  at  the  hip,  which  is  generally  flexion,  with  perhaps  abduc- 
tion, is  the  hardest  of  all  the  deformities  of  infantile  paralysis  to  cor- 
rect by  mechanical  means  on  account  of  the  difficulty  of  securing  a  fixed 
hold  upon  the  pelvis,  by  which  a  point  of  resistance  can  be  secured  in 
overcoming  the  flexion  of  the  thigh.  A  simple  apparatus  which  is  often 
of  use  is  furnished  by  two  caliper  Thomas  knee  splints,  or  one,  as  the 
case  may  be,  attached  to  a  leather  jacket  by  side  irons  hinged  opposite  to 
the  hips.  To  the  posterior  and  upper  parts  of  the  splints  are  attached 
straps  which  buckle  to  the  back  of  the  jacket,  and  while  by  the  jacket 
as  firm  a  hold  as  possible  is  taken  on  the  pelvis,  when  the  straps  are 
buckled  the  caliper  splints  pull  the  legs  backward  and  tend  to  overcome 
the  flexion  at  the  hips.  During  this  time  the  child  should  go  about  on 
crutches. 

But  the  contraction  is  sometimes  resistant,  and  it  is  necessary  to  con- 
fine the  patient  to  the  bed  and  to  employ  traction  of  a  considerable  amount 
and  such  measures  as  have  already  been  described  in  correction  of  the 
flexion  deformity  of  hip  disease. 


480  ORTHOPEDIC   SURGERY. 

Attempts  to  use  the  weight  of  the  leg  to  correct  this  flexion  in  severe 
cases  are  of  little  use.  It  might  be  imagined  that  if  the  knee  were 
straightened  by  a  ham  splint,  and  the  patient  allowed  to  go  about  on 
crutches  with  the  leg  projecting  in  front  of  him,  the  weight  of  it  by  drag- 
ging upon  the  shortened  tissues  Avould  stretch  them  and  the  flexion  would 
be  diminished.  But  the  leg  hangs  almost  perpendicularly  down  in  these 
cases,  owing  to  a  compensatory  lordosis  in  the  lumbar  spine,  which  takes 
place  at  once.  This  is  due  to  the  rotation  of  the  pelvis  upon  its  trans- 
verse axis,  which  occurs  naturally  enough  under  the  influence  of  the 
weight  of  the  leg  and  which  occasions  no  inconvenience  to  the  patient. 
A  similar  proceeding  occurs  when  a  weight  is  applied  to  the  patient's  leg 
lying  in  bed,  so  that  it  becomes  inefficient  also.  In  the  severer  cases 
operative  treatment  is  indicated. 

Flexion  of  the  knee  is  due  to  a  contraction  of  the  hamstring  muscles. 
The  deformity  in  children,  except  in  severe  cases,  can  be  corrected  by 
bandaging  the  leg  to  a  splint  which  takes  pressure  above  on  the  under 
side  of  the  thigh  and  below  is  fastened  to  the  heel.  The  appliance  is 
similar  to  that  described  above  as  a  support  to  the  knee.  In  resistant 
cases  some  pain  is  experienced  in  this  procedure,  but  the  pain  is  not 
great.  Patients  with  severe  deformity  should  be  confined  to  bed  during 
the  application  of  this  method  of  treatment,  but  in  the  milder  cases  they 
may  be  allowed  to  go  about. 

The  simplest  of  all  forms  of  correction  in  contraction  of  the  knee  is 
the  Thomas  knee  splint  or  a  modification  of  it,  but  jointed  splints  will  be 
found  convenient  in  some  instances  of  the  severest  type.  If  the  Thomas 
knee  splint  is  applied,  a  bandage  should  be  applied  in  front  of  the  thigh 
and  behind  the  calf;  by  tightening  these  a  decided  extension  force  is 
exerted  upon  the  knee. 

An  admirable  brace  for  correction  of  the  knee  is  one  similar  to  the 
simple  supporting  brace  with  two  uprights  already  described,  except 
that  it  should  be  jointed  at  the  knee  and  furnished  on  one  side  with  a 
worm  screw  and  ratchet,  so  that  by  the  use  of  a  key  the  splint  can 
be  set  with  any  desired  angle  at  the  knee.  A  leather  knee  cap  is  some- 
times necessary  to  obtain  counter-pressure  against  the  knee  in  front, 
but  in  other  cases  the  thigh  and  calf  lacings  are  sufficient  to  obtain  any 
desired  leverage.  These  leather  lacings  should  fit  with  especial  accuracy 
in  this  form  of  appliance.  To  be  applied  the  splint  should  be  flexed 
to  fit  the  contracted  knee  and  put  on  and  laced  firmly.  Then  with  the 
key  it  should  be  extended  nearly  to  the  point  of  endurance  and  worn  as 
straight  as  it  can  be  borne  for  an  indefinite  time.  At  first  these  joints 
prove  very  sensitive  and  painful,  but  they  soon  become  used  to  the  teu- 
sion  and  then  rapid  progress  can  be  made.  The  extension  of  a  contracted 
knee  may  in  the  case  of  an  adult  be  a  matter  of  many  months,  but  in 
children  it  requires  less  time,  unless  it  is  severe,  when  operation  may  be 


INFANTILE   SPINAL  PARALYSIS.  4  S  1 

required.  The  deformity  shows  a  strong  tendency  to  recur  when  the 
apparatus  is  removed. 

It  would  hardly  be  possible  to  reduce  the  knee  flexion  by  bandaging 
the  leg  to  a  ham  splint  and  making  traction  upon  the  knee;  the  resistance 
is  too  obstinate  except  in  very  slight  cases.  Correction  by  the  repeated 
application  of  plaster  bandages  to  the  knee,  extended  as  much  as  possible, 
will  often  be  found  satisfactory  and  painless  to  the  patient.  The  method, 
however,  is  a  slow  one  in  resistant  deformities. 

Deformities  of  the  Foot. — The  treatment  of  the  deformities  of  the  foot 
caused  by  infantile  paralysis  differs  very  little  from  that  described  in  the 
chapters  describing  deformities  of  the  foot.  Those  from  infantile  paraly- 
sis, however,  are  rarely  so  resistant,  and  yield  more  readily  to  mechani- 
cal treatment.  Talipes  equino -varus  and  varus  are  ordinarily  to  be  cor- 
rected by  the  varus  shoe,  so  often  described.  In  severe  cases  which  seem 
resistant,  and  in  adults,  tenotomy  will  save  time  and  annoyance.  Tali- 
pes valgus  is  rarely  the  result  of  contraction,  but  exists  more  as  a  purely 
static  deformity,  the  treatment  of  which  has  been  already  considered. 

Talipes  calcaneus  and  pes  cavus  are  not  susceptible  of  much  improve- 
ment by  mechanical  treatment.  Apparatus  which  depends  for  its  effi- 
ciency upon  a  strap  encircling  the  instep  and  pressing  upon  the  head  of 
the  astragalus  fails  to  accomplish  very  much.  At  times  it  is  of  use  to 
apply  an  outside  or  inside  Taylor  shoe,  as  the  case  may  be,  with  a  right- 
angle  stop  catch  joint  at  the  ankle,  which  prevents  dorsal  flexion  of  the 
foot  further  than  that  angle. 

Operative  Treatment. — The  measures  to  be  considered  are: 

(a)  Transplantation  of  muscles  or  tendons  (tendon  anastomosis). 

(b)  Tenotomy  or  fasciotomy. 

(c)  Forcible  straightening. 

(d)  Osteotomy  near  the  deformed  joints. 

(e)  Excision  and  arthrodesis. 

(a)  Tendon  transplantation  is  a  procedure  by  which  the-  proximal 
ends  of  healthy  or  partially  affected  muscles  are  attached  to  the  distal 
ends  of  the  tendons  of  paralyzed  muscles'  and  the  action  of  the  healthy 
muscle  is  transferred  to  the  attachment  of  the  paralyzed  one.  For  ex- 
ample, when  the  gastrocnemius  muscle  and  the  flexors  of  the  foot  are 
paralyzed,  the  tendon  of  one  peroneal  muscle  may  be  stitched  to  the 
tendo  Achillis  and  the  tendon  of  another  peroneal  muscle  to  the  distal 
end  of  the  flexor  longus  pollicis.  In  this  way  the  contraction  of  the 
peronei  results  in  plantar  flexion  of  the  foot. 

Muscles  may  also  be  implanted  in  other  muscles  or  fascia^,  as,  for 
example,  the  proximal  end  of  the  Sartorius  muscle  may  be  sewed  to  the 
rectus  anticus  when  the  latter  is  paralyzed  and  the  former  is  not.2 

1  Nicoladoni:*Cent.  f.  Chirurgie,  November  5th,  1881. 
-  Goldtlrwait :  Orth,  Trans.,  vol.  x. 

31 


482 


ORTHOPEDIC    SURGERY 


This  method  seems  to  offer  assistance  in  many  instances  to  patients 
who  would  otherwise  be  obliged  to  wear  apparatus  permanently.  The 
method  is  of  use  only  when  some  muscles  of  the  affected  limb  retain  a 

practical  amount  of  power.     It  has  no  place 
\  \  in  the  treatment  of  complete  paralysis  of  a 

limb. 

Some  of  the  applications  of  this  method 
already  used  which  have  proved  practicable 
are  as  follows : 

Calcaneo-  Valgus.  — If  the  peronei  are  in- 
tact the  tendon  of  the  peroneus  longus  is  cut 
from  its  attachment,  passed  under  the  tendo 
Achillis  and  attached  to  the  cut  end  of  the 
tendon  of  the  flexor  longus  pollicis,  while 
the  tendon  of  the  peroneus  brevis  is  cut  and 
sewed  to  the  tendo  Achillis.  To  obtain  a 
muscular  action  on  the  inner  side  of  the 
foot  in  such  cases  the  tendon  of  the  peroneus 
tertius  and  the  outer  tendons  of  the  com- 
mon extensor  may  be  attached  to  the  tendon 
of  the  tibialis  anticus  if  the  latter  is  par- 
alyzed. 

Talipes  Equinus. — If  the  common  ex- 
tensor has  escaped,  the  healthy  muscles 
should  be  attached  to  the  tendon  of  the 
tibialis  anticus  and  the  tendon  of  the  per- 
oneus tertius  also  added  to  that  of  the 
healthy  muscle. 

Paralysis  of  the  anterior  muscles  of  the 
thigh  may  be  benefited  when  the  sartorius 
has  escaped  by  the  attachment  of  that  mus- 
cle to  the  tendon  of  the  quadriceps  extensor 
just  above  the  inner  side  of  the  patella. 

These  are  far  from  being  all  the  available 
applications  of  the  method  and  each  case  must  be  studied  individually 
and  anatomically.  As  a  rule,  small  muscles  substituted  for  large  ones 
hypertrophy  and  accommodate  themselves  to  their  new  functions. 

The  field  of  operation  should  be  exposed  by  a  long  incision  exposing 
the  tendons  which  should  be  dissected  free  from  their  sheaths.  Tendons 
to  which  the  attachment  is  to  be  made  should  be  split  and  the  tendon 
of  the  healthy  muscle  passed  through  and  secured  by  a  quilted  stitch  as 
described  by  Goldthwait. '     The  tendon  passed  through  the  split  should 


Fig.  457.— Transplantation  of  Sar- 
torius to  Quadriceps  Tendon.  (Gold- 
thwait.) 


1  Boston  Med.  and  Surg.  Joura.,  January  9th,  1896. 


INFANTILE    SPINAL   PARALYSIS. 


483 


Fig.  458.  —  Poste- 
rior Paralysis,  Ex- 
cepting Peroneals. 
(Goldthwait.) 


Fig.  459.— Attempted  Direct  Dorsal  Flexion  in 
Same  Case.    (Goldthwait.) 


FIG.  461.— Same  Case  after  Operation.    Voluntary  Fig.  462.— Same  Case  after  Operation, 

dorsal  flexion.  Voluntary  extension. 


484 


ORTHOPEDIC    SURGERY. 


be  scored  by  a  knife  to  make  the  included  surface  rough.      Silk  is  the 
best  material  to  use  for  sutures.      To  estimate  the  degree  of  tension  nec- 


Fig.  403.— Method  for  Grafting.    (Goldthwait.) 


essary  the  foot  should  be  held  in  a  corrected  position  and  the  suturing 
done  with  a  safe  degree  of  tension  exerted  on  the  muscle,  as  the  danger 
lies  in  making  the  attached  muscle  too  long.     In  the  case  of  the  attach- 


Fifi.  4&5.  —  Operation.  Ten- 
don of  tibialis  anticus  split 
and  attached  to  the  peronetis 
tertius.    (Goldthwait.) 


Fir;.  466.— After  Operation. 


Fig.  467.— After  Operation. 


ment  of  two  small  tendons  to  each  other,  one  of  the  ordinary  forms  of 
tendon  suture  may  be  substituted  for  splitting. ] 

1  II.  A.  Wilson:  "International  Clinics,"  vol.  i.,  4th  series. 


INFANTILE   SPINAL   PARALYSIS. 


483 


After  operation  the  foot  should  be  put  up  in  plaster  in  the  correct 
position  for  some  weeks,  after  which  passive  motion  should  be  followed 
by  restricted  use.  Weight-bearing  should  be  begun  cautiously  and  the 
tendency  to  deformity  corrected  by  the  use  of  such  apparatus  as  may  be 
needed  for  a  while,  and  permanently  if  the  substituted  muscles  are  not 
strong  enough  to  correct  the  tendency  to  deformity. 

In  general,  however,  it  may  be  said  that  the  operation  performed 
under  proper  conditions  is  likely  to  do  away  with  the  future  use  of  ap- 
paratus. 

(b)  Tenotomy  or  fasciotomy  is  performed  in  resistant  cases  of  de- 
formity when  contracted  tissues  hold  the  limb  or  the  joint  in  malposi- 
tion. The  indications  are  the  same 
as  described  in  speaking  of  club- 
foot and  the  technique  differs  in  no 
way   from    that.     Immediate    cor- 


Fio.4 


Fig.  468.— Implantation  of  Peronei  on  to  Tendo 
Acbillis  and  Flexor  Longus  Hallucis.  (.Oold- 
tbwait.) 


Fig.  469.— Transplantation  of  Peroneus  Tertius 
and  Part  of  Common  Extensor  Tendon  to  Tibialis 
Anticus.    (Goldthwait.) 


rection  is  advisable  after  tenotomy  in  this  as  in  other  affections,  but 
here  over-correction  is  not  necessary.  Eelapse  is  less  likely  to  occur 
than  in  congenital  club-foot. 

Tenotomy  of  the  hip  for  contraction  in  the  flexed  position  may  in  the 
severest  cases  be  far  from  a  trifling  operation,  and  should  be  undertaken 
with  due  reserve.  The  contraction  is  due  not  only  to  the  contraction  of 
the  superficial  tissues,  but  of  the  deep  muscles  also  and  often  of  the  joint 
capsule,  and  for  that  reason,  when  the  operation  is  undertaken  in  a 
severe  case,  it  is  better  not  to  attempt  a  subcutaneous  tenotomy  but  at 
once  to  make  a  longitudinal  open  incision  of  considerable  length  over  the 
contracted  tissues,  and  preparation  should  be  made  to  go  as  deep  as  the 
psoas  tendon  if  necessary.  Although  the  contraction  often  seems  to  be 
superficial,  a  division  of  the  superficial  bands  generally  gives  but  little 


486  ORTHOPEDIC   SURGERY. 

relief,  and  all  constricting  bands  must  be  cut,  except  of  course  the  cap- 
sule of  the  hip-joint,  which  often  offers  resistance.  A  conservative 
method  to  pursue  is  to  cut  the  superficial  contracted  tissues  and  to  divide 
the  psoas  tendon  nearly  across,  cutting  also  those  deep  structures  which 
are  plainly  in  view,  in  order  to  be  able  to  check  hemorrhage  if  it  begins; 
then  to  close  .the  wound  and  to  apply  a  bed  extension  to  the  leg,  which 
will  have  the  effect  of  stretching  the  remaining  structures  quite  readily 
until  a  corrected  position  is  obtained. 

Division  of  the  ham-string  muscles  at  the  knee  is  often  required  in 
flexion  deformity  of  the  leg.  In  severe  cases  an  open  incision  is  often 
more  satisfactory  than  a  subcutaneous  tenotomy.  In  cases  of  long  stand- 
ing not  only  the  tendons  but  all  the  structures  at  the  back  of  the  knee  are 
contracted  and  an  extensive  division  of  them  may  be  needed. 

(c)  forcible  straightening  is  applicable  to  the  knee,  hip,  and  ankle, 
and  is,  of  course,  to  be  doue  under  complete  anaesthesia.  It  is  generally 
better  to  precede  this  by  tenotomy  of  resistant  tendons. 

(d)  Osteotomy  may  be  required  to  correct  severe  flexion  deformity  at 
the  hip,  and  at  the  knee  to  correct  the  knock -knee  and  flexion  at  the  same 
time.  At  the  hip  it  does  not  differ  from  the  ordinary  Gant  operation, 
and  is  necessary  only  in  cases  in  which  division  of  the  soft  parts  is  not 
enough  to  allow  sufficient  extension  of  the  thigh  on  the  pelvis. 

At  the  knee  a  simple  transverse  division  of  the  femur  is  made  just 
above  the  condyles,  allowing  correction  of  both  flexion  and  knock-knee  at 
the  same  time.  These  operations,  of  course,  have  no  effect  upon  the 
paralysis  as  such,  but  merely  serve  to  place  the  limb  in  a  position  suit- 
able for  weight-bearing.  After  operation  mechanical  support  is  usually 
necessary. 

(e)  Excision  and  Arthrodesis. — The  immediate  object  of  operative 
procedures  in  the  case  of  flail  joints  is  to  secure  a  stiff  joint  instead  of 
one  excessively  movable,  by  opening  and  scraping  out  the  synovial  cav- 
ity or  by  removing  the  articular  cartilages,  or  even  taking  a  thin  slice  off 
the  bones  on  each  side  of  the  joint  and  retaining  the  freshened  surfaces 
in  apposition,  so  that  ankylosis  may  be  favored  and  the  limb  may  thus 
become  of  more  use  in  locomotion. 

An  ankylosed  joint  is  thus  substituted  for  an  unduly  movable  one, 
and  supporting  apparatus  for  that  joint  is  not  required.  The  joint  is 
opened  as  for  excision  and  a  thin  layer  of  bone  removed  with  the  joint 
cartilage.  The  technique  of  the  operation  and  the  after-treatment  do  not 
differ  from  that  of  excision. 

From  the  results  attending  this  operation,  it  may  be  stated  that  in 
very  severe  deformities  and  in  patients  of  the  poorer  class  the  question 
of  resection'  of  the  joint  surfaces  of  the  knee  and  ankle  is  to  be  seriously 

1  Central bl.  f.  Chirurg.,  1887,  No.  46. 


INFANTILE    SPINAL   PARALYSIS.  487 

considered '  as  a  means  of  treatment  in  preference  to  the  application  of 
apparatus. 

In  other  cases  resection  of  joints2  is  to  be  considered  on  account  of 
the  extreme  bony  deformity  which  they  present,  as  in  severe  paralytic 
knock-knee/1  in  which  a  stiff  knee  rather  than  a  movable  one  is  desired.1 
If  the  latter  is  preferable  an  osteotomy  rather  than  an  excision  should  be 
done,  as  the  latter  leaves  a  stiff  joint.  The  deformity  of  knock -knee  or 
flexion  at  the  knee  can,  of  course,  be  corrected  by  the  plane  of  the  bone 
section  in  excision. 

1  Ap.  M.  Vance:  Boston  Med.  and  Surg.  Journ.,  May  6th,  1886,  p.  416. 
8 Franks  and  Stocker:  Trans,  of  Acad,  of  Med.  of  Iceland,  1885;  Lessor:  Cent. 
t  Chir.,  1879,  No.  31,  p.  497,  and  1887,  No.  46,  p.  797. 

3Kblliker:  Deutsch.  Zeit.  f.  Chir.,  xxiv.,  591 ;  Revue  de  Chir.,  1886,  vi.,  890. 
^Centralbl.  f.  Chirurg.,  1888,  No.  24. 


CHAPTER  XIV. 

CEREBRAL   PARALYSIS    OF   CHILDREN. 

Symptoms. — Idiocy. — Etiology  of  cerebral  paralysis. — Pathology  of  cerebral  paraly- 
sis.— Diagnosis. — Differential  diagnosis. — Prognosis. — Treatment. 

The  condition  was  first  described  by  Little,  von  Heine,  and  Adams, 
but  it  is  to  later  neurologists  that  we  owe  the  understanding  of  the  nature 
of  the  affection,  which  was  formerly  classed  along  with  infantile  paraly- 
sis. 

It  is  known  under  the  following  names:  Spastic  paralysis,  spastic 
hemiplegia,  etc.,  Little's  disease,  tetanoid  pseudo-paraplegia,  perma- 
nent tetanus  of  the  extremities,  spastische  Gliederstarre,  etc. 

The  onset  of  cerebral  paralysis  may  be  prenatal.  Cases  may  occur 
during  birth,  or  they  make  their  appearance  after  birth ;  in  the  latter  case 
the  majority  occur  in  the  first  three  years  of  life. 

The  affection  is  more  common  than  was  formerly  supposed.  At  the 
Children's  Hospital  185  cases  of  cerebral  paralysis  came  to. the  Surgical 
Out-Patient  Department,  while  300  cases  of  infantile  paralysis  appeared 
during  the  same  period.  During  a  definite  period  at  the  Hospital  for 
the  Ruptured  and  Crippled  in  New  York  91  children  affected  with  cere- 
bral paralysis  applied  for  treatment,  while  142  cases  of  spinal  paralysis 
were  seen. 

Motor  disturbances  in  children  which  are  due  to  cerebral  lesions  are 
manifested  clinically  in  one  of  three  ways:  (1)  as  a  single  hemiplegia-, 
(2)  as  a  diplegia;  (3)  as  a  paraplegia.  Contractures,  choreiform  move- 
ments, mental  impairment,  aphasia,  epilepsy,  inco-ordination,  etc.,  may 
be  the  accompaniments  of  any  one  of  these  forms. 

The  distribution  of  paralysis  in  225  cases  analyzed  by  Peterson  and 
Sachs  was  as  follows :  Right  hemiplegia,  81 ;  left  hemiplegia,  75 ;  di- 
plegia, 39;  paraplegia,  30 — total,  225. 

Symptoms  of  Cerebral  Paralysis  in  Cases  Occurring  After  Birth. — The 
onset  may  resemble  very  closely  that  of  infantile  spinal  paralysis;  it 
often  begins  with  an  illness  of  some  sort.  Frequently  paralysis  develops 
in  the  course  of  an  infectious  disease,  sometimes  after  an  attack  of  what 
seems  to  be  indigestion  or  a  slight  feverish  attack,  sometimes  after  a  fall 
or  blow  on  the  head.  Commonly  the  onset  is  marked  by  convulsions,  as 
in  52  out  of  90  of  Osier's  cases,  43  out  of  88  in  Wallenburg's,  30  out 
of  SO  in  Gaudard's,  12  out  of  26  in  the  Children's  Hospital  series,  and 


CEREBRAL   PARALYSIS    OF    CHILDREN.  489 

"in  more  than  half"  of  Gowers'  80  cases.  Delirium  or  screaming  spells 
may  accompany  the  onset.  Sometimes  however,  though  very  rarely, 
the  disease  develops  suddenly  in  perfectly  healthy  children  without  any 
febrile  or  other  disturbance,  or  it  may  develop  insidiously  without  dis- 
turbance enough  to  attract  attention.  From  the  second  year,  for  the 
first  six  or  seven  years  of  life,  the  liability  very  gradually  diminishes; 
the  number  of  cases,  however,  rising  slightly  at  the  time  of  the  second 
dentition;1  in  this  respect  it  offers  a  sharp  contrast  to  infantile  spinal 
paralysis. 

When  the  paralysis  is  noticed,  it  is  found  to  be  most  often  hemiplegic 
in  distribution.  Monoplegia  is  rare.  The  face  is  paralyzed  in  a  moder- 
ate proportion  of  all  cases  (twenty  per  cent  according  to  Sachs),  and  the  arm 
is  always  affected  more  severely  than  the  leg  and  recovers  more  slowly. 
The  facial  paralysis  ordinarily  is  not  complete  and  does  not  affect  the 
muscles  that  close  the  eyes.  It  disappears  first  of  all  the  paralyses,  and 
often  recovery  is  complete.  Strabismus  is  very  common.  The  paralyzed 
side  is  powerless,  but  sensation  is  generally  unimpaired;  coldness  and 
vascular  sluggishness  are  present  in  some  of  the  severer  cases.  The  re- 
flexes of  the  affected  side  are  much  increased  from  the  first,  a  sign  which 
is  of  the  greatest  assistance  in  diagnosis.  As  in  the  hemiplegia  of 
adults,  rigidity  of  the  affected  muscles  comes  on  in  about  seventy -five  per 
cent  of  all  cases  at  a  varying  time  after  the  onset  of  the  paralysis.  The 
rigidity,  when  present,  is  increased  by  any  attempt  to  use  the  limb ;  it  is 
excited  by  passive  manipulation  and  it  disappears  during  sleep,  and  usu- 
ally under  an  anaesthetic.  Post-hemiplegic  movements  follow  in  a  certain 
proportion  of  cases.2     Hemianopsia  may  be  present.3 

Aphasia  accompanies  probably  a  certain  proportion  of  cases  of  cere- 
bral paralysis,  but  it  is  often  transitory.4  It  is  always  motor  aphasia 
and  may  accompany  either  right  or  left  hemiplegia. 

Mental  enfeeblement,  varying  from  complete  idiocy  to  simple  back- 
wardness, develops  in  a  large  proportion  of  all  cases.  In  the  26  cases  in 
the  Children's  Hospital  series  only  6  had  what  was  classed  as  average 
intelligence,  and  one  of  these  was  aphasic  and  one  stuttered  very  badly. 
Of  the  rest,  7  were  idiotic,  8  feeble-minded,  and  4  very  backward,  and 
Wallenburg  in  his  160  cases  found  65  with  serious  mental  defects. 
Sachs  found  idiocy  present  in  35  per  cent  of  all  diplegias  and  in  60 
per  cent  of  paraplegias,  while  it  occurred  in  but  13  per  cent  of 
hemiplegias.       Merklin    calls    attention    to    the  fact  that  such  children 

1  Wallenburg :  Loc.  cit. 

2 Richardson :  Bost.  Med.  and  Surg.  Journ.,  May  20th.  1880;  Hammond:  "His. 
of  Nerv.  System,"  New  York,  1886,  p.  281;  Sharkey:  "Spasm  in  Chronic  Nerve 
Dis.,"  London,  1886,  p.  37  ;  Knapp  ;   Boston  Med.  and  Surg.  Jour.,  Nov.  22, 1888. 

3Freud:  "Cerebrale  Diplegien."  Vienna,  1892. 

•"Bernhardt:  Vircli.  Archiv,  Bd.  102. 


490 


ORTHOPEDIC    SURGERY. 


as  escape  mental  deterioration  in  childhood  often  develop  psychoses 
later  in  life. ' 

Epileptic  attacks  appear  in  the  paralyzed  limbs  and  thence  become 
generalized  in  one-quarter  to  one-half  of  all  cases  reported.  Ordinarily 
they  come  on  in  two  or  three  years  after  the  paralysis,  but  they  may  be 
delayed,  and  ten  or  even  thirty  years  may  elapse  sometimes  2 ;  on  the 
other  hand,  they  may  begin  within  a  few  weeks  of  the  onset. 

The  mind  may,  however,  remain  perfectly  clear  in  spite  of  a  severe 
hemiplegia,  and  no  sign  of  mental  deterioration  may  be  present  in  the 
early  or  the  late  history  of  the  disease. 

To  the  later  history  of  the  affection  belong  the  atrophy  and  contrac- 
tions of  the  limbs.     In  hemiplegia  the  affected  side  rarely  recovers  en- 


Fig.  470.— Atrophy  of  the  Hand  in  a  Case  of  Hemiplegia  of  Several  Years'  Duration.     (Knapp.) 


tirely,  and  often  the  growth  of  the  bones  is  retarded.  The  muscular  atro- 
phy, as  a  rule,  is  not  so  great  as  in  infantile  spinal  paralysis,  but  in 
certain  cases  the  muscles  waste  very  much.  In  severe  cases  there  is 
marked  arrest  of  growth  in  the  bones.  In  the  Children's  Hospital  series 
one  case  showed  a  shortening  of  two  inches  in  the  arm  after  the  paralysis 
had  lasted  seventeen  years,  and  three  other  cases  of  four,  seven,  and 
eight  years'  standing  showed  a  shortening  of  one  inch.  This  cannot  be 
the  atrophy  of  disuse,3  but  points  to  some  trophic  lesion.  It  has  been 
questioned  whether  or  not  serious  muscular  atrophy  does  not  mean  spinal 
involvement.  Hypertrophy  of  the  paralyzed  members  has  been  reported. 
The  permanent  contractions  that  come  on  are  most  noticeable  in  the 
arm,  and  as  a  rule  are  of  one  type  in  the  arm  and  leg.     In  the  former  the 

'Merklin:   St.  Petersburger  med.  Wochenschri f t,  1887. 

2Gowers:  "Epilepsy,"  London,  1880. 

3Forster:  Jahrbuch  f.  Kinderheilkumle,  N.  P.,  15,  261,  1880. 


CEREBRAL   PARALYSIS    OF    CHILDREN. 


49  i 


arm  is  held  close  to  the  side,  the  elbow  is  flexed  strongly  and  firmly,  the 
hand  is  flexed  and  the  fingers  are  drawn  into  the  palm,  usually  embracing 
the  thumb.  These  contractions  are  very  firm  and  resisting.  The  leg  in 
bad  cases  is  adducted  and  flexed  at  the  hip,  the  hamstring  muscles  of 
the  knee  have  contracted,  and  flexion  of  the  knee  has  resulted,  and  the 
foot  is  in  a  position  of  talipes  equino-varus  or  simple  equinus.  In  other 
cases'  only  the  finer  movements  of  the  hand  may  be  lost,  and  the  leg 
movements  may  be  impaired  only 
enough  to  cause  a  bad  limp. 

Post-  Paralytic  Disorders  of 
Movement.- — -In  certain  cases  of 
hemiplegia,    single   and   double,    a 


Fig.  471.— Standing  Position  in  Spastic  Paralysis. 


Fig.  472.— The  Gait  in  Spastic  Paraplegia. 


disturbance  of  motion  occurs  at  a  later  stage,  which  is  spoken  of  under 
many  different  names,  such  as  athetosis  and  chorea  spastica;  while  what 
is  called  "congenital  chorea"  in  many  cases  is  the  same  affection.2 

Gowers3  has  described  a  characteristic  slow  mobile  spasm,  which  he 
speaks  of  as  •'mobile  spasm."  The  paper  of  Knapp4  deals  in  detail  with 
the  character  of  these  movements. 


1  Journ.  of  Nerv.  and  Mental  Dis.,  August,  1887. 

2  Rau:  Neurol.  Centralblatt, ,  1887;  Greidenberg : 
181,  1886. 

3 Gowers:  "Dis.  of  Nerv.  Syst.,"  vol.  ii.,  p.  79. 


Archiv  f.  Psyckiatrie,  xvii., 
4  Knapp  :  Loc.  cit. 


i92  ORTHOPEDIC   SURGERY. 

Spastic  Condition  of  the  Muscles. — At  times  the  tonic  spasm  of  the 
muscles  becomes  so  much  the  most  prominent  feature  of  the  case  that  it 
is  spoken  of  as  spastic  paralysis  rather  than  as  hemiplegia,  especially  in 
diplegic  and  paraplegic  cases.  Spastic  paralysis  is  a  condition  charac- 
terized by  a  persistent  stiffness  and  constant  spasm  of  the  muscles  of  the 
legs  and  sometimes  of  the  arms ;  the  legs  are  straight  and  rigid,  and  the 
feet  are  extended,  and  when  an  attempt  is  made  to  walk  the  child  stands 
on  tiptoe,  and  often  the  spasm  of  the  adductor  muscles  is  so  great  that 
the  legs  are  crossed.  The  walk  is  almost  characteristic — a  clinging  gait, 
in  which  the  feet  are  scraped  along  the  floor  with  much  effort  and  strain- 
ing at  every  step,  if  indeed  the  spasm  is  not  so  great  that  walking  at  all 
is  out  of  the  question. 

In  general  this  affection  is  the  result  of  a  cerebral  lesion  and  a  de- 
scending degeneration  of  the  lateral  columns  of  the  spinal  cord.  There 
are,  however,  a  few  rare  cases  in  which  there  is  reason  to  believe  that  the 
affection  may  be  primarily  spinal. 

This  grade  of  affection  is  in  the  majority  of  cases  prenatal  or  caused  at 
birth,  and  represents  the  result  of  a  larger  brain  lesion  than  takes  place 
in  hemiplegia.  For  this  reason,  these  children  are  for  the  most  part 
feeble-minded  or  idiotic — as  one  might  reasonably  expect  as  the  result  of 
so  extensive  a  brain  lesion  occurring  at  so  early  an  age. 

However,  one  not  uncommonly  sees  children  of  more  than  average  in- 
telligence affected  with  spastic  paraplegia,  so  that  the  existence  of  spastic 
paralysis  is  by  no  means  evidence  of  mental  inferiority. 

Often  these  children  have  strabismus,  a  stupid,  idiotic  face,  the  saliva 
drips  from  the  mouth,  and  the  teeth  decay  very  early.1  Most  often  they 
walk  in  the  manner  described,  but  sometimes  the  muscular  spasm  is  so 
great  that  the  joints  are  so  fixed  as  to  be  useless.  In  the  milder  cases 
the  difficulty  in  walking  lies  in  the  fact  that  any  effort  to  use  the  limbs 
increases  the  muscular  spasm  and  tends  to  throw  the  leg  into  the  position 
of  extreme  adduction,  with  extension  of  the  foot  and  generally  slight 
flexion  of  the  knees  with  talipes  equinus.  It  is  often  impossible  to  de- 
monstrate the  increased  tendon  reflexes  either  at  the  knee  or  at  the  ankle 
on  account  of  the  great  stiffness  of  the  legs,  because  the  nmscles  are  con- 
tinually at  their  maximum  of  contraction.  The  electrical  reaction  in 
these  and  in  the  hemiplegia  cases  is  unchanged. 

In  certain  cases  the  spasm  is  so  great  that  the  patient  is  unable  to  stand 
alone.  When  supported,  the  thighs  are  adducted  very  closely  and  the 
toes  pointed  and  crossed. 

The  children  are  apt  to  be  uncleanly  in  their  habits  until  they  have 
reached  the  age  of  four  or  five  years  at  least.     The  mental  disability  may 


1  Alice  Loliier:  "De  l'Etat  de  la  Dentition  chez  les  Enfants  idiots  et  arrieres," 
Paris,  1887. 


CEREBRAL   PARALYSIS    OP    CHILDREN. 


4:93 


be  manifested  in  the  milder  cases  by  an  excessive  irritability  and  a  dis- 
position to  do  mischief  and  perhaps  to  destroy  playthings  wantonly. 
Furious  outbursts  of  temper  are  not  uncommon,  while  in  the  severer  cases 
stupidity  is  the  most  prominent  feature,  and  all  the  characteristics  of 
idiocy  are  in  many  cases  plainly  developed. 

The  cases  of  cerebral  paralysis  in  the  Children's  Hospital  series  were 
analyzed  with  regard  to  the  relation  of  spastic  paralysis  of  the  legs  and 


Fig.  473.— Attitude  in  Idiocy. 


hemiplegia.  There  were  twenty -six  hemiplegia  cases  and  in  nine  of 
these  patients  spastic  paralysis  of  both  legs  was  also  present. 

It  seems  as  if  spastic  paralysis  of  the  legs  were  occasionally  a  sequel 
of  simple  hemiplegia  coming  on  after  some  years. 

Inco- ordination  or  Idiocy. — This  condition  may  be  the  accompaniment 
of  cerebral  palsy  or  it  may  be  the  result  of  other  causes. 

The  classification  of  Sachs  is  as  follows : 


1.  Hereditary  idiocy 


\  (a)  congenital. 
j  (b)  developmental. 
(  after  traumatism. 

2.  Acquired  idiocy    -|  after  convulsions. 

(  after  infectious  diseases. 

3.  Myxedematous  idiocy. 

The  only  excuse  for  its  introduction  here  is  the  very  close  outward 
resemblance  that  these  conditions  present  on  superficial  examination  to  the 


494  ORTHOPEDIC   SURGERY. 

spastic  cases  already  considered ;  but  deiinite  paralysis  and  spastic  rigidity 
of  the  muscles  are  absent,  and  idiocy  obscures  everything.  If  patients  are 
seen  seated,  the  stupid  cross-eyed  look,  the  drooping  head,  and  the  drool- 
ing are  exactly  what  is  seen  in  the  severe  mental  enfeeblement  of  spastic 
paralysis,  or  hemiplegia.  But  put  the  child  on  his  feet  and  the  difference 
is  at  once  evident.  Either  his  muscles  are  so  lax  that  he  will  be  unable 
to  bear  his  weight  at  all,  or  he  will  stand  holding  his  parent's  hands  with 
his  feet  wide  apart,  his  knees  bent,  and  his  trunk  leaning  forward.  The 
whole  body  sways  to  and  fro  with  an  oscillating  movement,  and  the  sense 
of  equilibrium  seems  almost  wanting;  if  he  is  let  alone,  he  walks  in  a 
staggering,  uncertain  way,  with  many  falls.  From  this  the  condition 
grades  off  to  a  disability  so  great  that  the  child  cannot  even  sit  up;  when 
it  is  propped  up  the  head  lops  on  to  one  shoulder,  the  vertebral  column 
fails  to  support  the  trunk  and  bends  to  a  marked  degree,  and  every 
muscle  seems  limp  and  useless.  There  is  no  suspicion  of  muscular  rigid- 
ity or  localized  paralysis. 

Sensory  disturbances  are  not  uncommon,  and  often  a  pin  can  be  thrust 
through  the  skin  without  pain.  Nearly  all  these  children  have  strabis- 
mus, often  with  a  large  head  and  prow-shaped  forehead.  The  reflexes 
are  sometimes  normal  and  sometimes  increased,  while  the  legs  are  gen- 
erally flabby  and  cool,  and  the  hands  and  feet  often  undeveloped.  Every 
grade  of  the  condition  is  seen  from  that  described  above  to  complete  help- 
lessness. 

Etiology. 

The  etiology  of  prenatal  cases  of  cerebral  palsy  is  obscure.  Such  cases 
occur  in  neurotic  and  epileptic  families.  Traumatism  to  the  mother  during 
her  pregnancy,  severe  illness  of  the  mother,  severe  fright,  and  hereditary 
syphilis  are  among  the  causes.  The  etiology  of  cases  dating  from  birth 
is  better  formulated.  Asphyxia  at  birth,  prolonged  labors,  and  instru- 
mental deliveries  are  frequent  causes. 

Weber,  however,  made  161  autopsies  of  new-born  children,  and  in  81 
cases  in  which  the  spinal  canal  and  head  were  opened,  33  times  there  was 
extravasation  of  blood  from  the  spinal  and  cerebral  meninges.  The  in- 
fluence of  difficult  labor  as  a  cause  of  cerebral  paralysis  seems  to  have 
been  somewhat  overestimated.1  Of  Mr.  Little's  cases  a  large  proportion 
are  abnormal  only  in  the  occurrence  of  phenomena  which  are  of  little 
interest,  e.g.,  three  cases  are  considered  abnormal  because  the  cord  was 
wound  around  the  child's  neck.  In  the  33  cases  of  cerebral  paralysis  in 
which  the  labor  was  noted  in  the  Children's  Hospital  series,  17  were  born 
by  an  easy  labor  according  to  the  mother's  own  account.  The  forceps, 
however,  occasionally  causes  so  serious  an  injury  that  a  depression  of  the 

'"Mental  Affections  of  Childhood  and  Youth,"  London,  1887,  p.  44. 


CEREBRAL  PARALYSIS   OF   CHILDREN.  405 

skull  is  noted  years  afterward  on  the  side  opposite  to  the  hemiplegia. 
There  were  2  cases  of  hemiplegia  in  the  Children's  Hospital  series  in 
which  a  depression  in  the  skull  was  evident  four  and  eight  years  after 
the  beginning  of  the  paralysis.  Wallenburg,  in  his  100  cases,  assigned 
difficult  labor  as  a  cause  in  only  0  cases  and  does  not  mention  injury  from 
the  use  of  forceps. '  A  large  number  of  these  children  are  born  prema- 
turely, as  in  28  out  of  40  of  Little's  cases,  and  at  other  times  asphyxia 
neonatorum  seems  to  be  the  active  cause." 

In  cerebral  paralysis  acquired  after  birth  there  are  certain  well  formu- 
lated causes.  Acute  infectious  diseases  play  their  part,  cases  having 
occurred  after  measles,  scarlatina,  typhoid  fever,  smallpox,  tonsillitis, 
pneumonia,  pertussis,  cerebrospinal  meningitis,  gastro-enteritis,  mumps, 
diphtheria,  dysentery,  typhus  fever,  and  syphilis.  Fright  and  trauma 
are  two  other  accepted  causes.3 

In  a  large  number  of  cases  the  disease  seems  to  affect  perfectly 
healthy  children  without  any  assignable  cause.  The  indigestion  attacks, 
the  fever,  and  the  convulsions  attending  the  onset  cannot  fairly  be  as- 
signed as  causes.     The  disease  is  about  evenly  divided  between  the  sexes. 

Pathology. 

The  pathological  condition  is  much  the  same  in  hemiplegia,  diplegia, 
and  paraplegia.  These  conditions  in  general  are  due  to  embolism  or 
hemorrhage,  and  the  resulting  retardation  of  growth  of  the  affected 
portion  of  the  brain,  together  with  the  secondary  changes  in  the  spinal 
cord.  Autopsies  made  later  in  the  disease  show  pathological  changes 
which  are  more  extensive  and  less  definite  in  their  character.  Wast- 
ing and  sclerosis  of  a  greater  or  less  part  of  the  brain  and  the  con- 
dition known  as  porencephalus  are  what  one  finds  in  these  later  cases. 
These  seem  to  be  the  late  results  of  the  destructive  change  mentioned 
above,  which  have  occurred  in  a  growing  brain  and  have  retarded  its 
growth  and  have  produced  an  extensive  scar  formation  in  the  place  of 
cerebral  tissue. 

Porencephalus  occurs  as  a  loss  of  substance  in  the  form  of  cavities  or 
cysts,  situated  at  the  surface  of  the  brain  and  going  more  or  less  deeply 

'  Phila.  Med.  News,  1887,  ii.  Paper  by  Dr.  Parvin :  American  Journ.  Med.  Sci., 
1875;  Sinkler:  Med.  News,  1885,  vol.  i. 

2McNutt:  Am.  Journ.  of  Obst.,1885;  Parrot:  "Clinique  des  Nouveau-nes," 
Paris,  1877. 

3Obstet.  Trans.,  London,  vol.  xxvi.  ;  Boston  Med.  and  Surg.  Journal,  June  28th, 
1888;  see  also  three  cases  similar  in  Osier's  series  ;  Wallenburg,  Gowers,  and  Gau- 
ilard:  Loc.  cit.  ;  Marie:  Prog.  M£d.,  No.  36;  Richardiere :  "Etude  sur  le  Sclerose 
Enceph.  de  l'Enf.,"  etc.,  These  de  Paris ;  Jendrassik  and  Marie:  Arch,  de  Phys. 
Norm,  et  Path.,  v.,  51,  1885;  Osier;  Phila.  Med.  News,  July  14th,  1888;  Abercrom- 
bie :  St.  Barth.  Hosp.  Rep.,  xvi.,  p.  35,  and  Brit.  Med.  Journ.,  June  18th.  1887. 


496 


ORTHOPEDIC   SURGERY. 


into  it;  it  is  in  all  cases  the  motor  region  which  is  affected.  This  condi- 
tion of  porencephalia  may  be  of  greater  or  less  extent  and  unilateral  or 
bilateral.     Tf  either  porencephaly  or  sclerosis  is  unilateral,  hemiplegia 


Fi(i.  474.— Meningeal  Hemorrhage  at  Birth.    Death  on  the  twenty-second  day.     (McNutt.) 

results ;  if  the  lesion  is  bilateral,  double  hemiplegia  or  spastic  paraplegia 
is  the  clinical  manifestation.  These  lesions  represent  merely  the  late 
stages  of  a  process  originally  a  hemorrhage,  an  embolism,  or  a  localized 
encephalitis. 

The  pathology  of  the  condition  is,  in  short,  a  lesion  of  the  motor 
tract  of  the  brain  with  consequent  atrophy  and  retarded  development  of 


Fig.  475.— Cyst  Formed  by  Softening  of  Brain  Substance,  Secondary  to  Obstruction  of  the  Middle  Cere- 
bral Artery.    Child  of  nineteen  months.    (Sachs.) 

the  affected  portion,  and  descending  degeneration  of  the  pyramidal  tracts 
and  lateral  columns  of  the  cord.     From  the  extensive  atrophy  found 


CEREBRAL    PARALYSIS    OF    CHILDREN. 


P.*  7 


in  young  children  at  autopsy,  it  seems  that  unquestionably  sometimes 
the  disease  originates  in  defective  development  of  the  nervous  ^centres, 
especially  the  pyramidal  tracts,  rather  than  in  an  acute  cerebral  hemor- 
rhage or  embolism. 

Of  78  autopsies  analyzed  by  Sachs  and  Peterson  the  condition  was  as 
follows  : 

Atrophy,  sclerosis,  and  cysts, 


Porencephalia, 
Hemorrhage, 
Embolism,    . 
Thrombosis, 
Tubercle, 


40 

2 

23 

7 
o 

1 


78 

Osier  in  90  brains  found  a  vascular  lesion  in  16  only,  7  due  to  hem- 
orrhage and  9  to  embolism. 

77 


-.:•    "v  -- 


Fig.  -176.— Section  through  Portion  of  Motor  Cortex,  Removed  in  Operation  for  Localized  Epilepsy 
with  Left  Hemiplegia.  Boy  of  twelve  years.  Van  Gieson  stain.  P,  The  pia  much  thickened,  dips  be- 
tween folds  of  cortex ;  B,  increased  number  of  thickened  small  arteries  above  ;  to  right  a  large  artery 
with  thickened  walls ;  H,  a  recent  clot.    (Sachs.) 

The  theory  of  Strtimpell  that  the  condition  was  due  to  a  polienceph- 
alitis  similar  to  poliomyelitis  has  not  received  confirmation  nor  the 
support  of  modern  neurologists. 

1  Archiv  f.  Psych.,  Bd.  xvii.  ;    Archives  de  Physiol.,  3e  serie,  tODie  iv.,  1884; 
Sharkey:  Quoted  by  Osier,  loc.  cit.,  p.  143;  Blocq :  "Les  Contractures,"  Paris,  1888. 
32 


4:98 


ORTHOPEDIC   SURGERY. 


Cerebral  hemorrhages  in  children  differ  from  those  in  adults  in  that 
the  former  occur  in  and  near  the  cortex  while  the  latter  most  often  occur 
in  the  vicinity  of  the  internal  capsule. 

Heart  disease,  rheumatism,  scarlet  fever  are  the  conditions  which 
might  lead  one  to  suspect  embolism  rather  than  hemorrhage. 


Fig.  477.— Old  Hemorrhagic  Cyst.    Cyst  wall  cut  to  expose  tumor  underneath.    Right  hemiplegia  at  ago 
of  six  and  a  half  years.    Death  two  years  later.    (Sachs.) 

Osier1  summed  up  the  possible  causes  of  infantile  hemiplegia  as 
follows : 

(1)  Hemorrhage  occurring  during  violent  convulsions  or  during  a 
paroxysm  of  whooping-cough2  (or  at  birth). 

(2)  Post-febrile  processes,  (a)  embolic,3  ((>)  endo-  and  peri-arterial 
changes,4  (c)  encephalitis. 

(3)  Thrombosis  of  cerebral  veins.5 

There  seems  reason  to  believe  that  all  of  these  causes  at  times  have 
an  influence  singly  or  together  in  producing  cerebral  paralysis. 

To  enter  upon  a  discussion  of  the  pathological  condition  in  the  cases 
of  inco-ordination  spoken  of  above  would  be  to  introduce  the  very  exten- 
sive subject  of  the  pathology  of  idiocy.6 

1  Osier:  Med.  News,  Phila.,  August  11th,  1888,  p.  143. 

2  West:  London  Med.  Press  and  Circ,  1887. 
3Landouzy  and  Siredey  :  Rev.  de  Med.,  1885. 

4  Jendrassik  and  Marie :  Arch.  fiirPhys.,  1885. 

5Gowersand  Handford :  Brit.  Med.  Journal,  1887,  i.,  1098. 

6Cotard:  These  de  Paris,  1868;  Seibert:  Arch,  of  Pediatrics,  March,  1888,  168; 


CEREBRAL   PARALYSIS   OF   CHILDREN. 


±w 


Diagnosis. 

The  diagnostic  signs  of  hemiplegia  in  the  child  are  as  follows:  a 
motor  paralysis  of  one  or  both  sides  of  the  body  and  often  one  side  of 
the  face,  while  no  loss  of  sensation  is  present.  The  reflexes  of  the 
affected  side  are  increased  and  mental  impairment  is  common. 

When  spastic  paraplegia  is  present  it  is  characterized  by  tonic  con- 
traction of  the  muscles  which  yields  to  steady  resistance.     The  galvanic 


Fig.  478. 


FIG.  479. 


Figs.  478  and  479.— Spastic  Paralysis. 


reaction  is  normal.  At  times  the  muscular  rigidity  is  so  excessive  that 
the  exaggerated  knee  jerk  and  ankle  clonus  cannot  be  obtained.  In 
estimating  the  child's  mental  condition,  no  weight  whatever  can  be  at- 
tached to  the  parents'  account  of  the  patient's  capacity. 

The  differentiation  of  cerebral  paralysis  and  infantile  spinal  paralysis 
has  been  dealt  with. 

Beach:  Am.  Jour.  Ment.  Sci.,  June,  1883,  and  April,  1881;  Bunhuer:  Arch.  f. 
Psych.,  xii.,  3;  Tambarini :  Revist.  Sperim.,  vi.,  285;  Seibert:  Loc.  cit. 


500  ORTHOPEDIC    SURGERY. 

Obstetrical  paralysis1  might  be  mistaken  for  cerebral  lesions,  but  a 
careful  examination  would  determine  the  paralysis  to  be  limited  to  the 
distribution  of  some  especial  nerve  or  group  of  nerves.2  It  occurs  in  the 
distribution  of  the  facial  nerve  after  the  use  of  the  forceps,  but  it  may 
occur  in  one  of  the  extremities  in  consequence  of  the  stretching  of  the 
nerve  trunks  in  the  manual  extraction  of  the  child's  body.  It  often 
occurs  in  the  shoulder.  » 

Cerebral  tumors  may  cause  the  symptoms  of  hemiplegia,  and  a  diag- 
nosis of  this  condition  from  the  lesions  generally  causing  paralysis  would 
ordinarily  be  impossible. 3  Tumors  of  the  pons  or  cerebellum  would  cause 
symptoms  of  bilateral  rigidity  (spastic  paraplegia)  if  they  compressed 
the  motor  tracts. 

Pseudo-hypertrophic  paralysis,  the  pseudo-paralysis  of  rickets,  syph- 
ilis of  the  spinal  cord,  and  hereditary  spastic  paralysis  are  possible 
sources  of  an  error  of  diagnosis  in  obscure  cases.  Certain  cases  of 
chorea  prove  on  investigation  to  have  their  origin  in  a  slight  cerebral 
paralysis.     The  same  may  be  said  of  epilepsy. 

There  is  no  diagnostic  criterion  by  which  the  recognition  of  the  mis- 
cellaneous cases  of  idiocy  or  inco-ordination  may  be  surely  made,  so  that 
the  diagnosis  of  inco-ordination  or  idiocy  is  often  attended  with  much 
difficulty,  especially  in  young  children,  when  inability  to  walk  is  the 
only  definite  symptom.  Such  a  condition  may  result  from  rickets,  from 
feebleness,  from  simple  backwardness,  and  sometimes  from  paralysis  due 
to  unnoticed  Pott's  disease.  Under  these  circumstances  one  would  give 
much  weight  in  the  diagnosis  of  idiocy  to  the  child's  expression,  the 
ske  of  the  head,  the  presence  of  strabismus,  and  especially  an  oscillating, 
rhythmical  movement  of  the  head  or  whole  body  as  pointing  to  some 
cerebral  insufficiency.     Later  in  life  the  condition  is  only  too  apparent. 

Prognosis. 

The  prognosis  in  these  cases  should  be  most  guarded.  In  hemi- 
plegia there  are  two  things  to  be  said,  the  child  will  probably  live  and 
the  paralysis  will  probably  improve  somewhat.  The  unfavorable  things 
which  are  to  be  feared,  in  general,  are  more  likely  to  come  in  the 
earlier  cases  of  paralysis  than  in  those  that  occur  later  in  life.  These 
are :  mental  enfeeblement,  a  certain  amount  of  deformity  from  retarded 
growth  of  the  paralyzed  side,  and  epilepsy  in  about  half  the  cases,  per- 

1  Duchenne:  "Traite  de  l'Electrisation  Localisee,"  3d  ed. 

2Nadaud:  "Des  Par.  Obstetricales  des  Nouveau-nes,"  Paris,  1872. 

3 Seeligmiiller :  Jahrb.  f.  Khde.,  Bd.  xiii.  ;  Osier:  Am.  Journ.  Med.  ScL,  188"): 
Sharkey:  "Spasm  in  Chronic  Nerve  Disease,"  London,  1886;  Onimus:  Rev.  mens, 
des  Mai.  de  l'Enfance,  1883;  Lannois:  France  medicale,  1884;  Limard :  These  de 
Paris.  1884,  No.  85. 


CEREBRAL   PARALYSIS   OP   CHILDREN.  501 

haps  not  making  its  appearance  until  the  age  of  puberty.  Spastic  paraly- 
sis of  both  legs  is  to  be  feared  as  a  later  sequel  to  the  hemiplegia. 

On  the  other  hand,  in  many  instances  in  which  complete  helplessness 
exists  in  infancy,  marked  improvement  to  a  condition  of  comparative 
activity  is  sometimes  noticed. 

In  congenital  cases  the  occurrence  of  convulsions  in  the  early  weeks 
of  life  indicates  generally  a  severe  lesion.  If  the  mental  condition  con- 
tinues dull  idiocy  is  to  be  feared.  If  after  a  few  months  the  convulsions 
diminish  and  the  child  uses  its  legs  fairly  and  shows  interest  in  its  sur- 
roundings, the  prognosis  is  better.  Diplegia  and  paraplegia,  it  must  b«=) 
remembered,  are  more  often  associated  with  epilepsy  and  idiocy  than  is 
hemiplegia. 

In  acquired  cases  a  tendency  toward  recovery  in  movement  and  speech 
after  a  few  weeks  is  encouraging;  the  absence  of  such  tendency  is  un- 
favorable. Epilepsy  may  not  occur  at  once,  and  it  must  be  remembered 
that  about  half  the  cases  of  hemiplegia  develop  it  sooner  or  later.  The 
occurrence  of  convulsions  in  a  child  with  any  form  of  cerebral  paralysis 
is  unfavorable. 

With  regard  to  spastic  paraplegia,  it  is  safe  to  assert  in  most  cases 
that  the  child  will  improve  in  the  use  of  the  legs;  most  children  learn  to 
walk  at  the  age  of  five  or  six  and  to  talk  imperfectly.  The  general  ten- 
dency is  toward  improvement  in  walking  and  talking  for  many  years, 
although  it  must  be  borne  in  mind  that  the  final  result  in  well-marked 
cases  can  rarely  be  other  than  distressing.  Mental  enfeeblement  is  gen- 
erally present  from  the  first,  when  it  is  present  at  all,  but  it  may  become 
much  more  evident  as  the  years  go  on  when  the  demands  upon  the  intel- 
lect become  more  complicated  and  exacting. 

The  general  resistance  of  such  children  is  not  very  good,  they  are 
more  liable  than  other  children  to  fall  victims  to  general  diseases,  and 
their  inability  to  go  about  freely  renders  them  more  susceptible  to  illness. 
As  a  rule,  they  are  not  long-lived,  but  there  is  no  immediate  liability  to 
any  especial  disease,  simply  a  slightly  impaired  vitality.  No  question 
is  more  often  asked  than  this  one  about  the  child's  prospect  of  long  life. 

The  cases  of  inco-ordinatiou  or  idiocy  do  not  show  any  tendency  to 
spontaneous  improvement.  Sometimes  they  improve,  and  sometimes  they 
grow  worse,  but  oftenest  they  seem  to  remain  in  very  much  the  same 
condition. 

Treatment. 

During  the  onset  of  the  disease,  in  those  rare  cases  in  which  the  diag- 
nosis of  a  destructive  cerebral  lesion  is  made  so  early,  the  treatment 
should  be  the  same  that  is  ordinarily  advisable  in  any  convulsive  attack. 

In  the  great  majority  of  cases  the  nature  of  the  trouble  is  not  recog- 
nized until  the  acute  symptoms  have  passed  off  and  the  paralysis  has 


502  ORTHOPEDIC   SURGERY. 

become  well  established.  As  in  anterior  poliomyelitis  the  structural 
harm  has  been  done  and  no  treatment  addressed  to  the  centres  can  ac- 
complish very  much.  The  aim  must  be  to  keep  the  paralyzed  limb  as 
far  as  possible  from  trophic  changes  and  to  stimulate  the  muscles  to 
recover  as  far  as  possible  by  carefully  caring  for  their  condition.  Elec- 
tricity should  not  be  applied  to  the  brain.  The  proper  use  of  electricity 
is  in  its  stimulation  of  the  muscles.  Undoubtedly  benefit  results  from  a 
careful  course  of  this  treatment,  but  it  must  be  long  continued  and  it  is 
not  essential  to  improvement,  for  many  cases  do  perfectly  well  without 
any  use  of  electricity.  Galvanism  of  the  spine  with  an  ascending  or 
descending  current  is  deemed  of  use  in  cases  of  spastic  paralysis. 

Of  equal  or  greater  importance  is  a  systematic  and  persistent  course 
of  rubbing  and  manipulation  of  the  paralyzed  limbs.  In  spastic  paraly- 
sis, persistent  manipulations  with  strong  flexion  and  extension  of  the 
diseased  limbs  may  prove  of  great  benefit  in  preventing  a  disabling  rigid- 
ity and  in  maintaining  a  healthy  condition  of  the  muscles.  The  knees  and 
hips  should  be  forcibly  flexed  several  times  a  day  and  the  feet  bent  up 
beyond  a  right  angle  if  any  reasonable  degree  of  force  will  accomplish  it. 

In  spastic  paralysis  it  is  at  times  possible  to  accomplish  much  by 
muscular  training  and  exercise.  More  could  be  done  in  this  way  were  it 
not  for  the  mental  inability  of  so  many  of  these  patients,  which  makes 
it  impossible  for  them  to  co-operate  to  any  extent  in  such  treatment.  But 
in  those  cases  in  which  the  mind  is  bright  and  active,  the  patient  can  be 
trained  to  use  the  limbs  to  much  better  advantage  than  he  has  been 
doing,  just  as  a  person  who  stutters  can  be  improved  by  systematic  and 
repeated  exercises.  The  muscles  which  are  most  strongly  contracted  are 
the  thigh  adductors  and  the  calf  muscles.  Such  a  patient  should  be 
given  exercises  calculated  to  develop  the  abductor  muscles  and  the  flexors 
of  the  foot,  which  by  increased  power  will  in  a  measure  counterbalance 
the  muscles  which  are  so  powerful.  The  patient  should  lie  on  the  back 
on  a  hard  table,  and  should  separate  the  legs  as  far  as  possible  at  first 
without  being  touched,  and  then  against  slight  resistance.  The  legs  in 
the  extended  position  should  be  rotated  outward,  while  the  heels  are 
kept  together.  In  walking  the  patient  should  be  cautioned  to  go  very 
slowly,  to  lift  each  foot  well  off  of  the  ground  and  to  turn  out  the  toes 
with  much  care.  In  connection  with  massage  and  rubbing,  this  method 
of  treatment  is  capable  of  accomplishing  a  decided  change  in  the  method 
of  walking,  and  while  the  walk  still  is  stiff  and  unsteady  it  has  lost  the 
characteristic  scraping  and  dragging  of  the  spastic  gait.  Such  patients 
walk  with  much  less  fatigue  than  before  and  feel  much  more  steady  upon 
their  feet. 

The  mental  training  of  such  children  is  a  matter  of  the  greatest  im- 
portance in  order  to  render  as  active  as  possible  the  remaining  functions 
of  the  brain.     One  has  only  to  visit  an  institution  adapted  to  the  teach- 


CEREBRAL   PARALYSIS    OF    CHILDREN.  503 

ing  of  such  children  to  appreciate  the  great  advantages  that  such  special 
teaching  offers  over  that  of  the  ordinary  school  training.  The  disap- 
pearance of  the  aphasia  is  aided  by  systematic  training  and  it  always 
proves  more  tractable  than  in  the  adult.  The  epileptic  attacks  are  not 
likely  to  be  helped  by  medicinal  treatment,  on  account  of  the  nature  of 
the  lesion  causing  them. 

Apparatus  is  suited  to  the  treatment  of  the  milder  deformities  only. 
Talipes  equino-varus  of  a  mild  degree  may  be  temporarily  corrected  by  a 
proper  appliance,  such  as  a  Taylor  shoe.  The  paralysis  is  commonly  so 
incomplete  that  the  muscles  furnish  sufficient  support  to  the  affected  limb, 
but  owing  to  the  increased  reflex  excitability  and  to  imperfect  motor  im- 
pulses the  muscles  are  in  a  state  of  spasm  and  of  uselessness  from  the 
distorted  position.  Children  with  this  affection  are  brought  by  parents 
to  the  surgeon  with  the  request  that  braces  be  applied  to  make  the 
child  walk  and  that  spinal  supports  be  furnished.  In  general  the  de- 
formities are  to  be  treated  as  in  infantile  paralysis,  but  the  muscles  cannot 
be  stretched  to  an  extent  permitting  correction  of  the  deformity.  The 
deformity  returns  immediately  on  removal  of  the  appliance;  so  that, 
apart  from  the  temporary  rectification,  apparatus  is  of  little  advantage  in 
cerebral  paralysis.  Ketentive  apparatus,  however,  is  of  use  in  retaining 
the  limbs  in  proper  position  after  operation. 

Operative  Treatment. 

Post-hemiplegic  movements  are  at  times  relieved  by  placing  the  mem- 
ber at  rest  for  some  weeks  or  months  under  restraint.  For  example, 
an  arm  may  be  done  up  in  a  snug  plaster  bandage.  Clinical  evidence 
has  proved  that  tenotomy,  especially  of  the  tendo  Achillis,  in  this  class 
of  cases  is  of  much  use. ' 

The  writers  would  unhesitatingly  claim  great  benefit  for  the  operation 
in  suitable  cases.  The  orthopedic  surgeon  will  meet  a  certain  number  of 
cases  of  this  class  with  pronounced  equinus  deformity  of  one  or  both  feet. 
Locomotion  is  difficult  for  the  reason  that  it  is  impossible  for  the  patient 
to  bear  the  weight  upon  the  whole  sole  of  the  foot.  This  increased  diffi- 
culty is  sometimes  sufficient  to  deter  the  patient  from  efforts  at  locomo- 
tion and  always  adds  to  the  unsteadiness  of  gait.  If  tenotomy  of  the 
tendo  Achillis  is  done,  the  contraction  ceases,  and  though  the  strength  of 
the  muscle  is  not  lost  in  a  number  of  cases  which  have  been  watched  by 
the  writers  for  several  years,  there  is  tendency  to  a  reappearance  of  the 
equinus  deformity. 

In  a  few  instances  of  this  sort  a  practical  cure  has  been  gained  by 
tenotomy.      This  treatment  is  especially  suited  to  those  cases  in  which 

1  W.  N.  Bullard:  Boston  Med.  and  Surg.  Journ.,  February  16th.  1888. 


50-t 


ORTHOPEDIC   SURGERY. 


there  is  no  mental  disturbance  and  in  which  the  upper  extremities  are  not 
affected,  but  it  is  not  by  any  means  confined  to  these  cases. 

Division  of  the  hamstring  muscles  by  open  incision  should  be  done 
when  they  are  sufficiently  contracted  to  prevent  the  full  extension  of  the 
knee.      This  operation  is  preferable  to  tenotomy  because  it  offers  a  better 

chance  to  divide  contracted  tissues 
other  than  tendons. 

In  the  severer  cases  division  of 
the  adductor  tendons  is  also  of  ben- 
efit, as  the  adductor  spasm  often 
causes  the  knees  to  knock  together 
in  walking  and  is  a  serious  obstacle 
in  progression.  The  division  in 
mild  cases  may  be  by  subcutaneous 
tenotomy,  but  severe  cases  are  best 
treated  by  open  incision. 

The  writers  are  in  favor  of 
free  division  of  all  contracted  ten- 
dons or  muscles  if  necessary  in  spas- 
tic paralysis.  Their  personal  ex- 
perience has  led  them  to  regard  the 
operation  as  a  most  useful  one,  and 
they  have  never  seen  any  bad  re- 
sults from  it.  Even  in  adults  the 
operation  is  permissible  and  use- 
ful. If  it  is  not  done  thoroughly 
and  all  contracting  tissues  are  not 
divided,  relapse  may  occur.  If 
such  is  the  case  a  second  operation 
should  be  done. 

Eulenburg1  has  attempted  ten- 
don anastomosis  in  one  case  of  spastic  equino-varus  with  a  favorable  re- 
sult. The  tendo  Achillis  was  split  lengthwise  and  cut,  the  outer  half 
was  attached  to  the  peroneal  tendons  and  the  inner  half  was  left  free. 

Tenotomy  or  myotomy  may  also  be  useful  in  contraction  of  the  hand 
and  arm  in  cases  of  spastic  hemiplegia.  When  such  operations  are  under- 
taken they  should  be  thorough  and  all  contracted  structures  divided  which 
offer  an  impediment  to  the  proper  use  of  the  limb. 

In  the  severer  cases  open  incision  is  preferable  to  a  subcutaneous 
tenotomy. 

After  the  operation  the  limb  and  foot  should  be  immediately  corrected 
and  fixed  in  an  over-corrected  position,  until  the  tendon  has  united  and 


Fig.  480.— Spastic  Paralysis  before  Operation. 


Deutsch.  Hied.  Wochenschrift,  April  7th,  1898. 


CEREBRAL   PARALYSIS   OF   CHILDREN. 


505 


the  wound  has  healed.  The  writers  do  not  attempt  to  offer  any  theoret- 
ical explanation  of  the  benefit  gained,  but  they  simply  present  the 
marked  improvement  to  be  often  obtained  by  surgical  interference,  which 
is  much  greater  than  can  be  gained  by  the  use  of  any  appliance  or  by 
massage  or  electricity.  After  tenotomy,  correction  appliances  should  be 
used  for  a  few  months 
to  steady  the  limb? 
but  ultimately  may  be 
discontinued  and  per- 
manently discarded. 

The  possibility  of 
the  relief  of  epilepsy 
and  the  other  symp- 
toms of  cerebral  par- 
alysis by  surgical  in- 
terference at  the  seat 
of  the  brain  lesion  has 
not  been  overlooked. 
The  success  reached 
by  Horsley  and  others 
in  the  cure  of  epilepsy 
by  the  removal  of  tu- 
mors from  the  motor 
area  of  the  brain  has 
led  to  attempts  to  re- 
lieve the  epileptic  or 
spastic  condition  in 
these  cases  by  a  re- 
moval of  the  lesion  in 
the  cortex. 

With  regard  to  the 
relief  of  these  condi- 
tions by  operative 
measures  the  nature  of 
the  lesions  should   be 

borne  in  mind,  which  are,  as  we  have  seen :  (1 )  foci  of  destroyed  brain 
tissue  due  to  hemorrhage,  embolism,  or  perhaps  thrombosis;  (2)  scle- 
rosis; (3)  porencephalus.  In  every  case  a  defect  of  tissue;  there  is 
generally  nothing  to  be  removed;  to  make  the  hole  in  the  brain  bigger 
is  not  likely  to  help  matters;  the  existence  of  descending  degeneration 
of  the  cord  in  cases  of  long  standing  is  another  obstacle  to  successful 
relief.  The  opening  of  cysts  may  be  attended  b}r  improvement  when 
these  occur. 

But  the  practical  results  of  brain  operations  in  this  class  of  cases  have 


Fig.  481.— Spastic  Paralysis  after  operation. 


506  ORTHOPEDIC   SURGERY. 

not  been  on  the  whole  encouraging.  Such  cases  operated  on  for  the 
relief  of  epilepsy  are  reported  by  Horsley,  Oppenheim  (quoted  by  Freud), 
Gerster,  Wyeth,  Keen,  Weir,  Park,  Augell,  Starr,  and  others. 

In  exceptional  cases,  such  as  the  glioma  reported  by  Osier,  surgical 
interference  would  probably  have  been  of  much  benefit.  In  general, 
however,  in  the  cases  of  long  standing,  very  little  can  be  expected  of 
surgical  measures,  although  an  exploratory  trephining  might  lead  to  good 
results. 

When  balanitis  and  genital  irritation  under  the  foreskin  are  present, 
as  is  shown  by  painful  micturition  and  frequent  erections,  circumcision 
is  often  needed;  but  when  a  congenital  cerebral  defect  is  present,  as  is 
the  case  in  most  of  the  well-marked  instances  of  spastic  paralysis,  cir- 
cumcision is  useless  so  far  as  it  is  to  be  regarded  as  a  curative  measure. 

Summary. 

The  treatment  of  hemiplegia  in  the  early  stage  is,  in  a  word,  rubbing 
and  exercise  to  keep  the  muscles  in  good  condition,  and  mental  training; 
when  deformity  of  the  affected  limb  comes  on,  it  should  be  corrected  by 
apparatus  or  tenotomy.  Severe  spastic  paralysis  may  be  helped  by  cut- 
ting resistant  structures  when  the  limbs  are  deformed,  but  the  distortion 
is  not  likely  to  be  improved  by  purely  mechanical  treatment.  Kubbing 
and  gymnastics  are  of  much  benefit,  and  should  be  faithfully  tried. 


CHAPTER  XV. 

PSEUDO-HYPERTROPHIC    AND    OTHER    PARALYSES. 

Pseudo-hypertrophic  muscular  paralysis. — Progressive  muscular  atrophy.  —  Heredi- 
tary ataxia. — Obstetrical  paralysis. 

There  are  certain  motor  disturbances  affecting  children  which  come 
under  the  notice  of  the  orthopedic  surgeon  so  frequently  that  a  brief 
mention  of  their  characteristics  deserves  a  place  in  this  book.  They 
cannot,  of  course,  be  considered  in  detail,  but  are  simply  presented  in 
their  practical  surgical  and  therapeutic  aspect.     These  affections  are : 

I.  Pseudo-hypertrophic  muscular  paralysis.  Progressive  muscular 
atrophy. 

II.  Hereditary  locomotor  ataxia. 

I.   Pseudo-Hypertrophic  Muscular  Paralysis. 

Definition. — Pseudo-hypertrophic  muscular  paralysis  is  an  affection 
of  the  muscular  system  characterized  by  a  diminution  or  loss  of  the  func- 
tional energy  of  certain  muscles,  and  an  abnormal  increase  in  their  size, 
which,  together  with  diminution  in  the  size  of  other  muscles,  is  pathog- 
nomonic. The  affection  is  also  known  as  muscular  pseudo-hypertrophy, 
lipomatous  muscular  atrophy,  diffuse  muscular  lipomatosis,  myopachyn- 
sis  lipomatosa  (Uhde)  ;  Paralysie  myosclerosique,  paralysie  musculaire 
pseudo-hypertrophique.  Modern  classification  places  the  affection  among 
the  progressive  muscular  atrophies. 

Etiology. — The  etiology  of  the  affection  is  obscure.  The  disease  de- 
velops during  childhood  in  nearly  all  the  cases,  but  in  exceptional  in- 
stances its  appearance  is  delayed  until  the  age  of  eighteen  or  twenty 
years.  It  affects  males  more  commonly  than  females  in  about  the  pro- 
portion of  four  or  five  males  to  one  female.  The  disease  is  more  apt  to 
occur  in  family  groups  than  in  isolated  cases,  and  the  hereditary  element 
is  marked. 

Pathology. — The  pathological  condition  consists  in  the  overgrowth  of 
the  connective  tissue  in  the  muscles  and  the  wasting  of  the  muscular 
substance  proper,  while  a  deposit  of  fat  takes  place  to  a  greater  or  less 
extent.     No  constant  or  characteristic  pathological  condition  is  found  in 


508 


ORTHOPEDIC   SURGERY, 


the  spiual  cord,1  although  various  changes  have  been  described,  and  the 
condition  is  at  present  still  regarded  as  a  primary  affection.  - 

Symptoms. — The  first  symptoms  to  attract  attention  to  the  child's 
condition  are  muscular  feebleness  and  peculiarity  of  gait.  These  gener- 
ally precede  any  noticeable  enlargement  of  the  muscles.      Such  children 


Fig.  4K2.— Method  of  Kisiug  from  Prone  Position  in  Pseudo-Hypertrophic  Paralysis.    (From  series  of 

photographs.) 

tire  very  easily  in  walking  and  they  have  especial  difficulty  in  going  up 
and  down  stairs.  They  fall  often  and  in  rising  from  the  ground  they 
adopt  a  procedure  which  is  one  of  the  most  characteristic  features  of  the 
disease.  Inasmuch  as  on  account  of  muscular  weakness  they  cannot 
straighten  the  back  or  extend  the  knees  without  assistance,  they  rise 

JMed.  Chir.  Trans.,  lvii.,  p.  247,  also  Barth:  Arch.  f.  Khde.,  xii.,  1871,  121 
Eulenburg  and  Cohnheim:  Verhandlung  der  Berl.  nied.  Gesellschaft,  1866,  p.  191 
Lancet,  1881,  ii.,  060;  Byrom  Bramwell:  "Diseases  of  the  Sp.  Cord,"  Edin.,  1882 
Pekelharing :  Virch.  Archiv,  lxxxix.,  1882,  p.  228;  Sachs:  Loc.  cit.,  p.  431. 

2.Tacoby :  Am.  Journal  Nerv.  and  Mental  Disease,  1888. 


PSEUDOHYPERTROPHIC    .AND    OTIIKK    PARALYSES. 


509 


from  the  ground  in  the  manner  shown  in  Fig.  482,  using  the  muscles  of 
the  arms  to  accomplish  what  the  leg  and  back  muscles  cannot  do. 

These  children  tend  to  walk  with  legs  apart,  and  at  times  an  awk- 
ward gait  and  a  tendency  to  fall  are  for  a  long  period  the  only  symptoms 
of  the  affection. 

Such  patients  learn  to  walk  late  and  depend  much  in  their  progress 
upon  the  assistance  afforded  by  the  furniture,  upon  which  they  lean 
heavily.  In  kneeling  on  the  hands  and  knees  at  times  there  may  be 
noticed  a  characteristic  saddle-shaped  depression  of  the  back,  which  is 


FIG.  483.  -saddleback  Deformity  in  Muscular  Pseudo-hypertrophy. 


due  to  the  weakness  of  the  erector  spinee  muscles.  This  is  not  an  early 
accompaniment  of  the  disease,  but  is  a  characteristic  of  the  late  stage 
when  much  lordosis  is  also  present  in  standing. 

In  walking  these  children  throw  the  centre  of  gravity  of  the  body 
well  over  each  leg  in  turn  as  it  supports  the  body  weight.  In  this  way 
they  save  muscular  effort.  The  result  is  a  Avaddle  more  or  less  marked. 
They  may  stand  with  marked  lordosis  of  the  lumbar  spine,  chiefly  due 
to  a  weakness  of  the  lumbar  muscles.  The  lordosis  disappears  when  the 
patient  sits  down  and  a  bowing  backward  of  the  whole  vertebral  column 
takes  its  place. 

Mental  enfeeblement  is  associated  with  the  disease  in  many  cases. 
The  enlargement  of  the  muscles  is  usually  most  marked  in  the  calves  of 
the  legs.  On  this  account  the  parents  generally  feel  no  anxiety  because 
the  child  walks  late  or  feebly,  inasmuch  as  the  development  of  the  legs 
seems  so  remarkably  good. 

The  affected  muscles  are  hard  and  resistant  to  the  touch,  but  at  times 
the  sensation  in  handling  them  is  like  that  of  a  fatty  tumor. 

Atrophy  of  some  of  the  muscles  of  the  upper  extremity  is  apt  to  be 


510 


ORTHOPEDIC   SURGERY 


present.      The  scapular  muscles,  the  serrati,  the  latissiuius  dorsi,  aud  the 
pectoralis  major  are  often  wasted. 

Talipes  equinus  and  flexion  of  the  knees  and  hips  may  occur  from 
muscular  contraction.  Lateral  curvature  of  the  spine  may  follow,  and 
at  other  times  a  permanent  flexion  of  the  spine  occurs  from  weakness  of 
the  erector  spinae  muscles,  and  the  child  sits  bowed  forward.     But  these 

deformities  mark  only  the  late 
stage  of  the  affection,  which  is 
more  often  characterized  by  a  help- 
lessness more  or  less  complete. 

Neither  the  reflexes  nor  the 
electrical  reactions  are  modified  in 
any  degree  until  the  muscles  have 


Fig.  484.— Late  Stage  of    Pseudo-hypertrophic 
Paralysis,  with  Talipes  Equino- Varus.    (Sachs.) 


Fig.    485. 


-Late   Stage   of   Pseudo- hypertrophy. 
(Gowers.) 


reached  a  marked  stage  of  atrophy.  Then  they  are  diminished  in  pro- 
portion to  the  muscular  wasting  aud  finally  they  are  lost.  The  reaction 
of  degeneration  is  not  present.  Very  often  the  skin  over  the  affected 
limb  is  mottled  and  subject  to  vascular  changes,  indicating  some  vaso- 
motor disturbance. 

Diagnosis.— In  well-defined  cases  the  affection  in  its  later  stages  is 
not  likely  to  be  mistaken  for  anything  else.  The  peculiar  gait  with  the 
feet  wide  apart  and  a  reckless  disregard  of  falls,  the  characteristic  method 
of  rising  from  the  floor,  the  age  of  the  patient,  and  the  progressive  char- 
acter of  the  disease  all  suggest  this  affection.  If  examination  shows 
enlargement  of  the  calf  muscles  and  normal  or  diminished  reflexes  the 


PSEUDOHYPERTROPHIC    AND    OTHER   PARALYSES.  511 

diagnosis  may  be  considered  as  established.  Yet  of  even  greater  diag- 
nostic importance  than  the  enlargement  of  the  calf  muscles  is  the  com- 
bination of  enlargement  of  the  infraspinatus  and  wasting  of  the  latissi- 
mus  dorsi  and  pectoralis  major  muscles — a  state  of  affairs  to  which  great 
diagnostic  importance  is  to  be  attached. 

The  gait  in  early  hypertrophic  paralysis,  and  that  in  idiocy,  spastic 
paralysis,  in  the  paralysis  of  rickets  and  Pott's  disease,  and  in  simple 
weakness  have  very  much  in  common. 

Prognosis. — The  prognosis  is  as  unfavorable  as  possible.  Becovery 
is  all  but  unknown,1  and  arrest  of  the  disease  is  very  rare." 

The  course  of  the  disease  is  essentially  chronic.  The  earliest  stage  is 
made  manifest  by  muscular  feebleness,  and  passes  on  to  a  stage  in  which 
hypertrophy  of  the  muscles  becomes  evident.  This  stage  is  progressive 
and  at  the  end  of  it  the  pseudo-hypertrophy  reaches  its  maximum  and 
the  disease  becomes  stationary  and  remains  so  for  two  or  three  or  perhaps 
several  years.  Then  comes  a  time  of  increasing  feebleness  and  extension 
of  the  paralysis.  The  muscles  waste  and  the  power  of  movement  is  lost 
in  the  legs  and  arms.  In  this  deplorable  condition  the  patient  may  live 
on  until  death  comes  from  increasing  exhaustion  or  some  intercurrent 
disease. 

Treatment. — It  is  practically  hopeless  from  the  time  that  the  diagno- 
sis is  made,  and  there  is  no  reason  to  believe  that  drugs  have  had  any 
effect  in  retarding  its  progress.  Electricity  is  sometimes  of  benefit  in 
connection  with  other  treatment. 

There  is,  however,  one  rational  mode  of  treatment  in  systematic  mus- 
cular exercise  and  gymnastics,  calculated,  as  in  infantile  paralysis,  to 
keep  the  remaining  muscles  in  the  best  possible  state  of  nutrition  and  to 
ward  off  the  permanent  contractures. 

Tenotomy  is  of  use  as  soon  as  the  heels  are  drawn  up.  Often  walk- 
ing may  become  impossible,  chiefly  on  that  account,  and  division  of  the 
tendo  Achillis  on  both  sides  may  restore  for  a  time  the  power  of  walk- 
ing; also  tenotomy  of  the  hamstring  tendons  at  the  knee  may  be  indi- 
cated in  severe  cases. 


Progressive  Muscular  Atrophy. 

Progressive  muscular  atrophy  is  an  affection  characterized  by  a  wast- 
ing of  the  voluntary  muscles,  and  a  consequent  diminution  in  their 
power,  which  pursues  a  chronic  course  and  attacks  successively  individual 
muscles  and  groups  of  muscles. 

1  Duchenne:  Arch.  gen.  de  M6d.,  1868,  L,  pp.  5  and  6. 

2Donkin:  "Note  on  a  case  of  Pseudo-Hypertrophic  Paralysis,  Recovery,"  Brit. 
Med.  Journal,  April  15th,  1882. 


512  ORTHOPEDIC   SURGERY. 

Etiology. — In  muscular  atrophy  as  it  occurs  in  children,  the  only 
cause  assignable  is  a  congenital  tendency,  often  inherited.  But  at  times 
isolated  cases  are  met,  and  in  adults  other  causes  are  to  be  taken  into 
account. 

Males  are  move  often  affected  than  females,  and  the  time  of  onset  of 
the  disease  is  most  variable ;  it  may  begin  as  early  in  life  as  at  the  age 
of  three  years  or  as  late  as  sixty,  but  its  development  in  advanced  life  is 
rare. 

Progressive  muscular  atrophy  has,  since  the  days  of  Aran  and 
Duchenne,  been  subdivided  into  different  types. 

(1)  In  the  Aran-Duchenne  type  the  atrophy  begins  oftenest  in  the 
small  muscles  of  the  hand,  spreads  to  the  forearm  and  perhaps  the 
shoulders  and  back.  It  may  begin  in  the  muscles  of  the  thighs.  The 
atrophied  muscles  show  fibrillary  contractions,  and  the  reaction  of  de- 
generation is  present. 

The  affection  has  a  pathology  and  is  of  spinal  origin.  The  changes 
found  are  a  sclerotic  and  pigmentary  atrophy  of  the  ganglion  cells  of  the 
anterior  cornua,  an  inflammatory  condition  of  the  neuroglia,  and  cellular 
proliferation.     The  anterior  nerve  roots  are  affected  secondarily. 

(2)  The  hereditary  form  is  of  the  same  general  type  as  the  preceding. 
It  is  very  unusual  and  may  occur  in  more  than  one  member  of  a  family. 

(3)  The  peroneal  form  or  leg  type  of  progressive  muscular  atrophy 
affects  in  most  cases  the  lower  extremities.  The  extensor  muscles  of  the 
toes  are  first  affected,  then  the  small  muscles  of  the  feet,  and  finally  the 
entire  leg.      Talipes  equinus  or  equino-varus  is  a  common  result. 

The  development  of  double  club-foot  with  progressive  wasting  of  the 
lower  extremities  is  very  suggestive  of  this  type  of  the  affection.  It  may 
affect  the  upper  extremities  first  and  then  the  lower. 

Sensory  changes  are  generally  present.  The  reflexes  in  the  lower 
extremities  may  be  diminished  or  lost  if  the  disease  is  sufficiently  ad- 
vanced. The  electrical  reactions,  as  a  rule,  are  altered  both  quantita- 
tively and  qualitatively.  Two  cases  of  club-foot  occurring  in  this  type 
were  successfully  operated  on  by  Gribney.1 

The  changes  in  the  muscles  consist  in  atrophy  of  the  fibres,  a  loss  of 
transverse  striation,  and  a  proliferation  of  the  nuclei.  There  are  present 
degenerations  of  the  nerves,  but  changes  of  importance  in  the  spinal  cord 
have  not  been  established. 

The  two  remaining  types  along  with  pseudo-hypertrophic  paralysis 
are  to  be  classed  as  primary  myopathies  or  primary  muscular  dystrophies 
in  that  they  are  not  associated  with  demonstrable  lesions  in  the  spinal 
cord. 

(4)  Erb's  type.     The  juvenile  form  of  progressive  muscular  atrophy 

1  Sachs:  Loc.  cit.,  p.  413. 


PSEUDOHYPERTROPHIC    AND    OTHER    PARALYSES.  513 

is  very  rare  and  is  characterized  by  progressive  wasting  of  certain  groups 
of  muscles.  These  are  the  muscles  of  the  shoulder  girdle,  the  upper  arm, 
the  pelvic  girdle,  the  thigh,  and  the  back.  The  forearm  and  leg  muscles 
remain,  for  a  long  time  at  least,  intact.  There  are  no  fibrillary  contrac- 
tions, no  reaction  of  degeneration,  and  no  sensory  disturbances. 

(5)  The  Landouzy-Dejerine  type  or  the  facio-scapulo-humeral  variety 
occurs  at  times  in  children.  The  muscles  of  the  face  are  first  affected 
and  the  atrophy  spreads  to  the  shoulder  and  arm  muscles.  In  excep- 
tional cases  this  type  may  begin  in  the  arms  or  legs.  The  reaction  of 
degeneration  and  fibrillary  twitching  are  never  present. 

Treatment. — The  medical  treatment  of  all  these  affections  is  hopeless. 
When  muscular  contractions  occur  tendons  should  be  cut  and  deformities 
rectified.  Rest  to  the  atrophied  muscles,  massage,  and  electricity  are 
useful. 

II.   Hereditary  Ataxia. 

Hereditary  ataxia  deserves  mention  as  a  serious  motor  disorder  which 
is  sometimes  met  in  children.  It  is  dependent  upon  a  family  predis- 
position, but  is  not  often  directly  inherited,  but  more  commonly  appears 
in  several  members  of  one  generation.  Hence  the  name  of  family  ataxia. 
It  is  also  known  as  Friedreich's  disease.  Other  names  are,  hereditary 
ataxic  paraplegia,  and  degenerative  ataxia.     The  cases  are  rare. 

Etiology. — Aside  from  the  influence  of  a  congenital  tendency  the 
cause  of  the  disease  is  as  yet  unknown.1  The  disease  develops  most  often 
early  in  life.     The  sexes  seem  equally  liable  to  the  affection. 

Pathology. — In  examining  sections  of  the  cord  in  these  cases,  a  de- 
generation of  the  lateral  columns,  with  a  more  intense  and  plainly 
marked  sclerosis  of  the  posterior  columns,  is  found.  This  is  similar  to 
the  lesion  of  locomotor  ataxia. 

Symptoms. — The  symptoms  resemble  very  closely  those  of  locomotor 
ataxia,  except  that  the  lightning  pains  of  the  early  stage  and  crises  are 
not  so  marked  as  in  the  latter  affection.  Hereditary  ataxia,  moreover, 
involves  the  upper  extremities  more  severely  and  earlier  in  the  course  of 
the  affection. 

The  patient  notices  a  feeling  of  weakness  and  uncertainty  in  walking, 
and  soon  it  becomes  apparent  to  others  that  the  motions  of  the  legs  are 
not  properly  co-ordinated.  The  feet  are  placed  wide  apart  in  standing, 
and  in  walking  the  gait  is  practically  that  of  locomotor  ataxia.  The 
movements  of  the  hands  become  irregular  and  inco-ordinate,  and  a  jerky 
irregularity  develops  in  the  movements  of  the  head  and  neck,  so  much 
so  that  it  may  assume  the  aspect  of  an  irregular  tremor.  Speech  may 
also  be  impaired. 

1  Gowers     Vol.  i.,  p.  380  ;  Shattuck:  Bost.  Med.  and  Surg.  Journal,  vol.  cxviii., 
7,  p.  168  ,  Smith  .  Boston  Med.  and  Surg.  Journ.,  October  15th,  1885. 
33 


5U 


ORTHOPEDIC   SURGERY. 


The  knee-jerk  disappears,  but  the  plantar  reflex  remains.  Sensation 
is  affected  in  varying  degrees  in  different  cases,  and  trophic  disturbances 
of  the  skin  are  not  present.  As  a  rule  the  sphincter  muscles  are  not 
affected.  Nystagmus  is  often  present;  the  Argyll-Eobertson  pupil  is 
absent. 

Deformities  are  apt  to  come  on  in  the  later  stages  of  the  disease.  In 
cases  seen  by  the  writers,  marked  rotary  lateral  curvature  was  present, 
and  talipes  equinus  or  equino-varus  and  permanent  flexion  of  the  knee 
are  likely  to  occur. 

Diagnosis. — In  a  clearly  marked  case,  the  walk  is  characteristic  and 
exactly  like  that  of  ordinary  locomotor  ataxia.     The  deep  reflexes  are 


Fig.  486.— Deformity  of  the  Feet  In  a  Case  of  Friedreich's  Disease.    Hyperextension  of  the  toes  and  club- 
foot.   (Marie.) 


diminished  or  absent  and  there  is  a  certain  amount  of  disturbance  of 
sensation ;  the  electrical  reactions  are  normal.  Isolated  cases  occur  but 
rarely,  and  one  finds  most  often  a  history  of  some  such  affection  in  other 
members  of  the  same  family,  which  of  course  aids  very  much  in  the 
diagnosis. 

Prognosis. — The  disease  is  essentially  progressive,  and  the  prognosis 
is  bad  in  proportion  to  the  rapidity  of  progress.  Death  usually  occurs 
from  intercurrent  affections,  but  sometimes  the  disease  lasts  for  thirty 
years  or  more  and  does  not  seem  to  have  shortened  life.  It  is  not  likely 
to  cause  death  inside  of  ten  or  twelve  years  at  the  least,  and  nothing 
must  be  expected  from  treatment. 

Treatment. — The  treatment  should  be  similar  to  that  in  common  use 
in  locomotor  ataxia  of  the  regular  type.  The  general  hygiene  of  the 
patient  should  be  most  carefully  regulated,  and  skilful  massage  sometimes 
accomplishes  much  in  keeping  up  the  nutrition  of  the  muscles  and  thus 
diminishing  the  patient's  disability.     Electricity  in  the  same  way  is  of 


PSEUDOHYPERTROPHIC   AND   OTHER   PARALYSES.  515 

use,  but  it  is  distinctly  second  in  importance  to  proper  massage.  De- 
formities should  be  corrected  by  tenotomy,  etc.,  as  they  occur. 

Among  similar  affections  are  the  cerebellar  type  of  hereditary  ataxia 
described  by  Marie,  differing  chiefly  in  having  exaggerated  reflexes  and 
ocular  symptoms  in  addition  to  those  described  above. 

Hereditary  spastic  paralysis  must  be  mentioned  as  an  affection  of  in- 
terest chiefly  to  neurologists,  and  not  to  the  surgeon  essentially  different 
from  the  class  described  under  cerebral  paralysis. 

Obstetrical  Paralysis. 

Obstetrical  paralysis  of  the  shoulder  is  an  affection  which  is  fairly 
common  and  often  results  in  a  disabled  arm.  It  occurs  most  often  after 
difficult  labors  when  traction  is  made  upon  the  head  in  head  presenta- 
tions, or  upon  the  trunk  when  the  head  is  delivered  last.  It  may  occur, 
however,  after  normal  labors,  as  in  a  case  recorded  by  one  of  the  writers.1 

It  seems  plain  that  the  injury  is  due  to  a  stretching  and  in  some  cases 
a  rupture  of  the  two  upper  roots  of  the  brachial  plexus.  It  has  been 
found  experimentally  that  the  two  upper  roots  give  way  first  when  trac- 
tion is  made,  becoming  very  tense  when  the  shoulder  is  pulled  down, 
while  the  three  lower  roots  remain  lax  under  the  same  conditions.2  The 
paralysis  is  of  Erb's  type  and  the  nerves  involved  are  the  circumflex, 
suprascapular,  musculo-cutaneous,  and  musculo-spiral. 

The  theory  that  it  is  a  form  of  anterior  poliomyelitis  has  not  met  with 
general  acceptance. 

It  has  been  suggested  that  the  paralysis  is  due  to  the  pinching  of 
the  plexus  between  the  clavicle  and  the  transverse  processes  of  the 
vertebrae. 

The  condition  is  made  manifest  immediately  after  birth  by  an  inabil- 
ity to  use  one  arm ;  it  hangs  powerless  at  the  side,  with  the  palm  turned 
backward,  and  often  the  fingers  are  flexed  tightly.  If  the  arm  is  lifted 
from  the  side  it  falls  lifelessly  back  into  place,  and  although  movement 
of  the  fingers  is  generally  present,  it  is  impossible  to  use  the  arm  to  any 
extent  on  account  of  the  paralysis  of  the  shoulder  muscles. 

The  prognosis  in  the  severer  cases  is  not  good  as  to  recovery.  The 
general  experience  of  the  writers  has  been  that  cases  of  complete  paraly- 
sis of  the  arm  following  delivery  which  do  not  recover  within  a  few 
weeks  improve  with  great  slowness,  and  rarely  have  a  very  useful  arm. 
A  patient,  nineteen  years  old,  was  seen  by  one  of  the  writers  when  the 
case  had  been  under  good  treatment  from  the  first.  The  affected  arm 
was  four  inches  shorter  than  the  other,  and  although  the  grasp  of  the 

1  Boston  Med.  and  Surg.  Journal,  1892. 

2  J.  S.  Stone:  Boston  Med.  and  Surg.  Journ.,  1899. 


516  ORTHOPEDIC   SURGERY. 

hand  was  good,  the  arm  could  not  be  lifted  from  the  side.  The  patient 
was  able  to  touch  the  chin  with  the  affected  hand,  but  could  not  raise  it 
to  the  mouth  or  opposite  shoulder.  The  use  of  the  arm  was,  however, 
improving  with  each  year.  This  will  serve  as  an  example  of  the  average 
outlook  in  severe  cases. 

The  treatment  should  consist  in  the  use  of  a  sling  or  supporting  band- 
age at  first  to  prevent  stretching  of  the  joint  capsule  and  muscles.  Later 
massage  and  electricity  are  likely  to  be  of  use. 

In  cases  with  contraction  myotomy  of  the  pectoralis  major  muscle 
followed  by  retention  of  the  arm  in  a  position  to  prevent  contraction  of 
the  scar  is  of  use. 


OHAPTEK  XVI. 

FUNCTIONAL    AFFECTIONS    OF    THE    .JOINTS. 

Definition. — Etiology      and     occurrence. — Frequency. — Symptoms. — Hip. — Knee. — 
Ankle. — Diagnosis. — Prognosis. — Treatment. 

Definition. 

Functional  disorders  of  this  class  are  usually  termed  hysterical  or 
neuromimetic ;  but  both  terms  are  misleading.  The  first  by  common 
usage  has  become  almost  an  expression  of  opprobrium,  and  the  second  by 
its  derivation  suggests  mimicry.  These  cases  may  exist  not  only  with- 
out deceit,  but  without  any  manifestation  of  imitation,  intentional  or  un- 
conscious. 

The  manifestations  of  this  nervous  disorder  which  will  be  considered 
here,  are  the  affections  of  this  class  involving  the  spine,  hip,  knee,  and 
ankle,  although  the  other  joints  can  hardly  be  considered  exempt. 

These  disorders  are  probably  dependent  upon  a  disturbed  nervous 
condition,  perhaps  due  to  a  disordered  blood  supply,  brought  about  by 
nervous  exhaustion  from  over-growth,  from  disease,  nerve  strain,  or  from 
trauma.  They  are  here  termed  functional,  because  there  is  no  evidence, 
clinical  or  pathological,  of  organic  disease. 

It  is  ordinarily  supposed  that  these  disorders  are  seen  in  persons  of 
an  excitable,  emotional  temperament.  Such  is  usually  the  case,  but  ex- 
ceptionally the  most  aggravated  type  of  functional  affections  may  be  seen 
in  persons  of  calm  and  composed  demeanor  manifesting  no  exaggeration 
in  statement  or  manner. 

It  is  extremely  difficult  for  a  surgeon  not  learned  as  a  neurologist  to 
understand  the  nature  of  functional  affections.  The  surgeon's  training 
leads  him  to  regard  as  of  slight  importance  whatever  has  no  pathological 
basis  and  no  tangible  objective  reality;  but  it  is  to  be  borne  in  mind  that 
in  all  these  cases  an  undiscovered  cause  in  all  probability  exists,  as  defi- 
nite and  un discoverable  as  the  nerve  changes  in  tetanus  or  hydrophobia. 

The  condition  of  impairment  of  nervous  resistance  to  pain  is  seen  in 
the  dentist's  chair  after  several  hours  of  suffering,  on  the  operating-table 
when  no  anaesthetics  are  used,  and  sometimes  in  the  recovery  from  an- 
aesthesia or  from  intoxication.  After  prolonged  extreme  pain  all  indi- 
viduals may  become  hysterical.  The  sound  in  a  telephone  is  louder  if 
the  receiver  is  more  sensitive,  and  in  functional  affections  slight  periph- 


518  ORTHOPEDIC   SURGERY. 

eral  irritation  usually  unnoticed  will  produce  uncommon  mental  impres- 
sion if  the  recording  nerve  centres  have  become  abnormally  sensitive. 

The  concentration  of  the  attention  upon  the  affected  part  is  another 
most  powerful  factor  in  producing  and  perpetuating  the  phenomena  of 
functional  joint  disease.  The  familiar  experiment  of  thinking  fixedly  of 
one  finger  serves  to  bring  out  a  series  of  sensations  in  it  which  are  not 
present  in  the  other  fingers,  and  illustrates  as  well  as  anything  can  do 
the  power  which  concentrated  attention  possesses. 

Etiology  and  Occurrence. 

A  study  of  the  etiology  of  this  class  is  disappointing.  They  belong 
to  a  large  group  of  disorders  of  the  nervous  system,  which  present  an 
interesting  puzzle  as  to  the  nature  of  the  causation.  As  a  predisposing 
influence,  an  emotional  temperament,  which  enters  largely  into  the  ex- 
aggerated statement  of  all  subjective  symptoms,  must  be  considered  in  all 
cases.  The  influence  of  home  training  and  discipline  in  the  development 
of  this  temperament  is  important,  as  well  as  is  heredity.  Persons  broken 
down  in  health  by  suffering  or  chronic  disease  become  naturally  in  time 
incapable  of  bearing  pain,  and  the  statement  of  such  patients  is  exagger- 
ated and  the  endurance  lessened. 

Trauma  is  a  frequent  exciting  cause.  In  certain  cases  the  pain  caused 
by  a  synovitis,  for  instance,  seems  to  be  perpetuated  after  its  legitimate 
cause  has  disappeared.  This  is  due  to  the  patient's  abnormal  sensitive- 
ness and  self-concentration.  Such  sensations  are  to  be  classed  as  "  habit 
pains."  Again,  slight  sources  of  peripheral  irritation,  too  slight  to  be 
an  inconvenience  to  normal  persons,  may  be  a  cause  of  severe  symptoms 
in  neurasthenics.  Among  such  causes  may  be  mentioned  a  short  leg  or  a 
weakened  foot  of  slight  degree. 

This  condition  of  hypersensitiveness  is  sometimes  to  be  seen  in  young 
girls  about  the  time  of  puberty,  and  in  elderly  women  at  the  time  of  the 
menopause,  rarely  in  young  children.  Women  in  young  and  middle 
adult  life  are  the  most  frequent  sufferers.  How  far  sexual  irritation 
enters  into  these  cases  as  a  causative  influence  cannot  be  said  with  cer- 
tainty, but  in  some  cases  it  appears  to  be  one  of  the  disturbing  factors 
which  make  up  the  disease.  The  statement  cannot  be  too  strongly  made 
that,  although  these  affections  are  seen  mostly  in  young  women  at  or 
after  puberty,  it  must  not  be  overlooked  that  they  occasionally  occur  in 
young  children,  in  boys,  and  also  in  men.  Such  cases  are,  however,  not 
common. 

Frequency. 

The  frequency  of  these  affections  is  not  generally  recognized.  Why 
a  disturbance  of  the  nervous  centres  should  result  in  the  manifestation  of 
a  group  of  symptoms  so  closely  resembling  those  of  serious  joint  disease 


* 

FUNCTIONAL   AFFECTIONS   OF   THE   JOINTS.  519 

is  but  one  of  the  many  unexplained  phases  of  this  disorder.  The  same 
may  be  said  of  the  direction  of  these  symptoms  to  any  particular  joint; 
except  that  traumatism  is  in  many  cases  the  cause  which  determines  the 
concentration  of  the  attention  upon  some  one  joint.  The  direct  exciting 
cause  of  the  appearance  of  this  disease  is  frequently  not  discovered.    . 

Symptoms. 

These  affections  may  begin  gradually,  or  they  may  be  seen  following 
trauma.  Again  they  may  be  the  outcome  of  a  protracted  convalescence 
from  some  joint  injury.  The  symptoms  presented  may  not  be  charac- 
teristic of  this  disorder,  except  that  they  are  usually  much  exaggerated 
and  out  of  proportion  to  the  local  signs.  There  is  usually  a  condition  of 
hyperesthesia,  especially  of  the  skin,  which  manifests  itself  most  clearly 
when  any  manipulation  of  the  affected  part  is  attempted.  Although  this 
is  a  very  important  factor  in  the  determination  of  this  class  of  affections, 
the  absence  of  this  hyperesthesia  must  not  be  taken  as  sufficient  evidence 
to  exclude  the  disease.  Another  characteristic  feature  of  these  disorders 
is  the  fact  that  the  objective  signs  vary  from  time  to  time.  The  stigmata 
of  hysteria  accompany  many  of  these  cases  and  when  present  are  of  great 
diagnostic  importance. 

Organic  and  functional  disease  are  at  times  associated.  A  young 
woman  with  hip  disease  of  a  mild  character  will  sometimes  so  exaggerate 
and  emphasize  her  symptoms  that  the  case  may  appear  to  be  of  the  most 
acute  sort,  but  careful  examination  will  perhaps  show  that  the  disease  is 
convalescent  and  that  the  real  condition  is  very  favorable.  This  can 
be  detected  only  by  a  careful  examination  showing  that  the  muscular 
stiffness  varies  much  with  the  attention  of  the  patient  and  that  much 
pain  is  attributed  to  the  slightest  manipulation  which  can  easily  be  per- 
formed without  suffering  or  muscular  spasm  when  the  attention  of  the 
patient  is  diverted,  while  the  muscular  rigidity  of  chronic  joint  disease 
is  a  constant  and  not  a  variable  resistance  to  passive  manipulation. 

Atrophy  may  be  considerable,  but  it  is  generally  not  more  than  can 
be  accounted  for  by  disuse.  It  must  be  remembered,  however,  that  this 
wasting  may  take  place  to  a  marked  degree,  but  it  differs  very  decidedly 
in  amount  from  the  extreme  atrophy  which  is  seen  in  real  joint  lesions. 

Distortions  of  the  affected  limbs  have  nothing  characteristic  about 
them,  except  that  they  may  or  may  not  follow  the  malpositions  of  the  limb 
which  occur  in  real  joint  disease.  The  hysterical  knee-joint  is  often  flexed, 
the  hip  may  be  flexed  and  perhaps  adducted  or  abducted. 

In  short  the  symptoms  of  functional  joint  disease  have  one  distinctive 
characteristic,  they  are  chiefly  subjective,  and  objective  signs  of  structural 
trouble  are  absent  or  not  prominent.  A  familiarity  with  the  objective 
signs  of  disease  of  the  various  joints  is  of  course  necessary  in  making 


520  ORTHOPEDIC   SURGERY.. 

the  diagnosis  of  functional  troubles,  and  the  foregoing  chapters  have  dealt 
with  those  objective  signs. 

Certain  symptoms  often  associated  with  functional  disorders  are  ova- 
rian tenderness  and  pain,  baso-occipital  headache,  a  feeling  of  suffocation 
as  if  a  lump  were  lodged  in  the  throat,  and  symptoms  of  this  class. 

The  association  of  uterine  disorders  is  common,  and  also  another  fre- 
quent accompaniment  is  found  in  the  presence  of  errors  of  refraction  in 
the  eyes. 

The  surface  cemperature  may  be  increased,  local  sweating  may  occur, 
and  neurologists  describe  some  swelling  as  an  accompaniment  of  certain 
cases  of  functional  disorder  of  the  joints. 

The  correction  of  all  sources  of  peripheral  irritation  is  of  course  a 
matter  of  much  importance. 

Spine. 
Functional  affections  of  the  spine  have  been  considered  in  Chapter  III. 

Hip. 

The  symptoms  which  may  present  themselves  under  these  conditions 
at  the  hip-joint  may  resemble  hip  disease  in  many  particulars.  There  is 
often  complaint  of  a  severe  pain  in  the  limb,  and  any  attempt  to  move 
the  hip  elicits  expression  of  pain.  There  may  be  an  absence  of  atrophy, 
and  the  pain  is  more  likely  to  be  localized  at  the  hip  than  at  the  knee, 
which  is  the  reverse  of  what  happens  in  true  hip  disease.  Unconscious 
movements  at  the  hip-joint  may  be  made  more  freely  than  in  the  painful 
stages  of  hip  disease.  In  some  instances,  marked  fixation  at  the  hip- 
joint  may  constantly  be  present,  but  usually  the  stiffness  in  examination 
of  the  hip  is  great,  but  unconscious  movements  at  the  hip  as  in  stooping 
are  freer.  The  stiffness  is  more  the  stiffness  of  apprehension  than  the 
limited  motion  of  early  disease  of  the  joint.  The  affection  is  rare  in 
children,  but  the  writers  can  mention  cases  in  girls  of  eight  and  ten 
years. 

The  deformity  may  be  marked  and  persistent,  recurring  quickly  after 
reduction,  but  frequently  the  normal  position  is  retained  by  very  slight 
means,  by  a  force  far  too  little  in  amount  to  produce  of  itself  any  actual 
effect. 

Creaking  of  the  joint  may  be  present  in  both  hip  and  knee  in  func- 
tional affections.  Uncommon  at  the  hip,  it  is  a  frequeut  symptom  of 
functional  knee-joint  disease.  This  symptom  is  described  in  many  books 
as  one  to  be  sought  for  in  destructive  joint  disease;  it  may  be  said  again 
that  it  is  not  a  common  sign  in  joint  disease.  When  destructive  changes 
in  the  joint  have  progressed  so  far  as  to  destroy  the  cartilage  covering 
the  ends  of  the  bones,  the  joint  disease  will  have  assumed  so  acute  a 


FUNCTIONAL    AFFECTIONS    OF    THE    JOINTS.  521 

type  that  muscular  spasm  to  a  marked  degree  will  be  present  and  prevent 
any  motion  between  the  eroded  surfaces.  This  will  naturally  prevent 
the  perception  of  any  grating  without  the  use  of  an  anaesthetic,  a  pro- 
ceeding which  is  wholly  unnecessary  and  will  allow  a  grating  to  be  felt 
only  in  the  more  advanced  cases  in  which  the  diagnosis  must  already  be 
clear. 

In  all  cases  of  functional  affection  of  the  hip  any  inequality  in  the 
length  of  the  legs  should  be  corrected  as  well  as  any  abnormality  of  the 
foot. 

Knee. 

Functional  disease  of  the  knee-joints  often  simulates  either  chronic 
synovitis  or  ostitis.  Pain  and  tenderness  may  be  present,  creaking  is 
noted  as  an  occasional  symptom  in  functional  affections,  and  at  times 
there  seems  to  be  present  an  increase  of  surface  temperature,  which  is 
apparently  due  to  superficial  hypersemia.  It  may  not  be  constantly  pres- 
ent in-  the  same  case,  and  it  varies  in  a  way  altogether  unlike  the  be- 
havior of  the  heat  of  chronic  inflammation.  More  commonly  the  surface 
temperature  of  the  affected  side  is  reduced.  The  knee  may  be  flexed, 
but  during  sleep  that  position  may  be  involuntarily  abandoned  or  the 
leg  can  be  easily  straightened,  offering  but  little  resistance.  Contraction 
of  the  knee  is  often  absent. 

A  moderate  degree  of  muscular  atrophy  is  present,  and  in  some  cases 
of  prolonged  disease  of  the  joint  peri-articular  adhesions  may  be  formed 
with  contractions  from  adaptive  shortening  of  the  muscles. 

In  rare  instances  some  swelling  of  the  peri-articular  tissues  around 
the  knee  is  observed  in  this  class  of  cases.  The  swelling  is  transitory 
and  does  not  involve  the  joint  proper. 

Nowhere  does  the  diagnosis  present  greater  difficulty  than  at  the 
knee,  where  traumatism  may  loosen  the  semilunar  cartilages  to  a  slight 
degree  or  do  some  similar  injury.  The  diagnosis  of  functional  disease 
can  be  made  only  after  the  careful  exclusion  of  all  organic  pathological 
conditions  in  both  knee  and  foot.  As  our  knowledge  of  abnormal  con- 
ditions in  the  knee-joint  becomes  more  exact  fewer  cases  are  classed  as 
functional. 

Ankle. 

An  hysterical  condition  of  the  ankle  is  not  infrequent.  It  is  most 
commonly  met  as  a  result  of  sprains  which  have  been  treated  for  too 
long  a  time  by  rest  and  fixation.  A  condition  of  muscular  weakness, 
enfeebled  circulation,  and  apprehension  at  slight  pain  ensues,  and  no  at- 
tempt at  the  proper  means  of  securing  recovery  is  made,  for  the  reason 
that  the  first  attempt  to  use  the  disabled  joint  is  painful  and  pain  is 
regarded  as  a  symptom  indicative  of  inflammation. 


522  ORTHOPEDIC   SURGERY. 

In  functional  disease  of  the  ankle  an  attitude  similar  to  talipes  varus 
or  of  flat-foot  may  be  seen.  In  one  case  of  talipes  varus  seen  by  the 
writers  there  was  an  exaggerated  limp,  and  when  the  patient's  attention 
was  eugaged  the  foot  could  be  replaced  and  even  over-corrected,  yet  at 
other  times  it  presented  a  firm  resistant  contraction.  The  distorted  atti- 
tude in  both  the  knee  and  the  ankle  may  be  so  constantly  assumed  as  to 
cause  a  contraction  of  the  hamstrings  or  tendo  Achillis. 

At  the  ankle  most  cases  of  functional  affection  are  either  the  outcome 
of  trauma  or  are  associated  with  some  abnormality  of  the  foot. 

The  functional  affections  of  the  other  joints  present  no  points  worthy 
of  especial  mention. 

Diagnosis. 

So  much  has  been  said  about  the  characteristics  of  these  affections  in 
speaking  of  the  various  joints  that  there  is  scarcely  need  of  mention  here. 
It  may,  however,  be  said  that  the  symptoms  are  often  those  of  organic 
joint  disease,  but  that  the  groups  of  objective  physical  signs  are  deficient 
and  inconsistent  with  each  other.  The  objective  signs  vary  and  are  not 
so  severe  as  the  symptoms  would  lead  one  to  expect.  Pain  is  the  promi- 
nent feature  and  muscular  rigidity  and  similar  symptoms  are  of  varying 
severity,  according  to  the  concentration  of  the  patient's  attention.  The 
presence  of  superficial  hyperesthesia  and  of  signs  characteristic  of  hysteria 
with  an  emotional  temperament  are  facts  which  should  excite  attention. 

In  examining  patients  in  whom  a  functional  affection  is  suspected, 
much  information  can  be  gained  by  watching  the  movements  of  the  patient 
in  getting  out  of  bed,  moving  in  bed,  etc.  The  limbs  or  back  should  be 
bared,  and  the  unaided  movements  watched.  Those  suffering  from  or- 
ganic disease  of  the  hip  or  spine  show  a  constant  stiffness  or  attempt  to 
guard  or  protect  the  affected  limb,  which  is  not  displayed  to  so  marked  a 
degree  in  purely  functional  affections. 

The  diagnosis  to  be  of  value  must  in  practically  all  cases  be  made  by 
a  process  of  exclusion.  Again  it  must  be  remembered  that  functional 
and  organic  disease  may  exist  in  the  same  joint,  that  is,  legitimate  symp- 
toms may  be  so  exaggerated  as  to  constitute  a  functional  affection. 

Prognosis. 

If  left  to  itself,  a  true  functional  affection  of  the  spine  or  joints  may 
improve  gradually  without  special  treatment,  or  it  may  remain  unchanged 
until  the  joint  becomes  really  injured  by  the  continued  inaction.  In 
some  cases  a  sudden  and  profound  mental  impression  may  prove  stronger 
than  the  idea  of  local  disease  and  a  cure  is  effected.  It  is  this  that  the 
surgeon  strives  to  accomplish  in  certain  cases,  it  is  this  that  may  be 


FUNCTIONAL   AFFECTIONS   OF   THE   JOINTS.  523 

brought  about  by  faith  cure  or  charlatanry,  and  rational  treatment  of  a 
similar  sort  can  likewise  win  excellent  results  if  properly  carried  out. 

The  age  of  the  patient  and  the  duration  of  the  affection  are  important 
in  determining  the  outlook.  The  older  the  patient  and  the  longer  the 
course  of  the  disease  the  less  favorable  is  the  prognosis. 

The  existence  of  some  peripheral  source  of  irritation,  such  as  is  so 
often  found  in  an  error  of  refraction  in  the  cornea  or  in  a  misplaced 
uterus  or  a  short  leg  or  a  weakened  foot,  renders  it  likely  that  the  gen- 
eral condition  will  be  helped  by  a  removal  of  the  irritating  cause  and 
renders  the  immediate  prognosis  perhaps  more  favorable. 

Treatment. 

In  few  disorders  is  a  routine  treatment  of  less  use  than  in  functional 
affections  of  the  joints  or  spine.  In  severe  cases  the  treatment  begins 
with  a  contest  of  intelligence  between  the  patient  and  physician,  and 
treatment  is  futile  unless  the  superiority  of  the  physician  is  evident  to 
both  the  physician  himself  and  the  patient.  Especially  important,  from 
the  outset  to  the  end  of  the  treatment,  is  an  established  diagnosis,  on 
which  the  surgeon  can  rely.  To  attempt  to  follow  out  a  treatment  which 
shall  be  suitable  to  either  functional  or  organic  disease  is  fatal  to  a  suc- 
cessful issue.  Temporizing  on  the  part  of  the  physician  at  once  makes 
successful  treatment  almost  impossible.  A  definite  plan  of  treatment 
must  be  formulated  and  adhered  to. 

The  disorder  usually  manifests  itself  as  a  disability  of  a  limb,  the 
object  of  treatment  being  to  overcome  the  disability.  Various  methods 
will  be  needed  to  effect  this. 

It  is  first  necessary  that  the  patient  be  brought  into  as  nearly  normal 
a  general  condition  as  possible.  The  improvement  of  the  local  condition 
is  then  to  be  considered  and  estimated,  and  finally  the  patient  is  to  be 
trained  to  regain  the  use  of  the  disabled  limb.  Another  aspect  of  the 
case  lies  in  the  moral  management  of  the  patient,  a  matter  which  will  be 
successful  or  not  generally  in  proportion  to  the  tact  and  judgment  of  the 
practitioner.  Some  patients  can  be  commanded  to  walk  and  will  do  so 
and  a  cure  is  accomplished,  while  in  the  majority  of  cases  to  attempt  a 
measure  of  this  sort  would  lead  to  a  permanent  loss  of  influence  on  ac- 
count of  the  failure  of  the  surgeon  to  have  his  directions  carried  out. 
Elaboration  of  treatment  is  desirable  in  many  cases  and  a  rigid  adher- 
ence to  a  careful  and  continuous  routine  of  exercises,  feeding,  and  medi- 
cation must  be  insisted  upon.  In  no  class  of  diseases  do  proper  placebos 
work  more  good.  A  full  description  of  the  measures  necessary  for  the 
proper  treatment  of  neurasthenic  patients  does  not  fall  within  the  scope 
of  this  work,  but  this  class  of  cases  cannot  be  successfully  treated  unless 
due  attention  is  given  to  regulating  and  improving  diet  and  general  con- 
dition, and  correcting  sleeplessness 


524:  ORTHOPEDIC   SURGERY. 

For  the  treatment  of  the  local  condition,  the  physician  has  to  decide 
between  the  necessity  of  correcting  any  existing  distortion  or  local  im- 
proper conditions  of  circulation  or  muscular  weakness  of  the  limb  or 
back,  and  the  danger  of  increasing  the  expectant  attention  of  the  patient 
by  too  great  attention  to  the  local  condition.  It  is  for  this  reason  that 
counter-irritation  and  the  cautery  are  to  be  avoided.  It  is  essential  that 
the  local  condition  should  not  be  made  light  of  by  the  surgeon,  and  the 
reality  of  the  symptoms  must  be  accepted  and  the  disability  recognized. 
A  probable  hypothesis  explaining  the  condition  must  be  assumed,  and 
treatment  based  upon  this  should  be  carefully  and  consistently  carried 
out.  Any  statement  that  the  affection  is  a  trivial  nervous  disorder  or 
that  it  can  be  overcome  by  exercise  of  the  will  is  in  most  cases  an  error. 

An  important  part  of  local  treatment  is  the  improvement  of  the  circu- 
lation in  the  part  affected,  and  strengthening  of  the  surrounding  muscles. 
This  can  be  done  by  massage,  local  hot-air  baths,  electricity,  and  gym- 
nastics, and  the  functions  of  the  part  gradually  resumed  by  slight  passive 
motion. 

In  general  the  beneficial  effect  of  the  local  measures  adopted  must  be 
insisted  on,  and  by  a  graduated  amount  of  enforced  exercise  progressively 
increased,  the  patient  may  be  surprised  into  finding  herself  daily  doing 
more  without  feeling  more  pain.  Sometimes  it  may  be  only  practicable 
to  make  the  patient  take  two  steps  a  day,  but  the  advance  to  three  and 
four  steps  is  an  important  gain.  It  may  be  repeated  that  without  a  cer- 
tainty on  the  physician's  part  that  he  is  dealing  with  a  "functional  affec- 
tion and  without  a  rigid  adherence  to  his  formulated  plan  of  treatment, 
success  is  not  often  to  be  obtained. 

Great  benefit  can  be  obtained  by  graduated  exercises  in  this  class  of 
cases.  Another  useful  way  of  accomplishing  this  result  is  by  means  of 
mechanical  passive  and  active  exercises  according  to  the  method  intro- 
duced by  Zander. 

Appliances  as  a  rule  should  be  avoided— but  in  some  cases  they  are 
temporarily  needed,  to  enable  the  patient  to  go  about  more  freely  in 
cases  with  marked  muscular  weakness.  They  should  be  discarded  as 
soon  as  is  practicable ;  in  the  severer  forms  crutches  will  be  an  aid  when 
walking  is  first  attempted,  and  plaster  jackets  have  been  occasionally 
used  with  advantage.  They  should,  however,  be  employed  only  for  a 
short  time,  as  they  increase  the  muscular  Aveakness.  The  same  is  true, 
but  to  a  less  degree,  of  the  lighter  forms  of  appliances— spring  corsets 
and  similar  light  appliances. 

In  functional  affections  of  the  hip,  knee,  and  ankle  it  is  sometimes 
necessary  to  employ  crutches  in  order  to  give  locomotion  and  exercise. 
Crutches  should  be  used  sparingly,  and  only  temporarily,  inasmuch  as 
there  is  danger  of  the  patient  becoming  habituated  to  them. 

When  contractions  and  malposition  of  the  limbs  are  present,  these 


FUNCTIONAL   AFFECTIONS   OF   THE    JOINTS.  525 

should  be  corrected  either  by  operation  or  by  mechanical  means.  Opera- 
tive measures  are  usually  simple,  as  under  an  anaesthetic  the  limb  can  be 
pulled  readily  into  normal  position,  while  only  in  severe  cases  is  tenot- 
omy of  the  resisting  muscles  needed.  Appliances  will  be  required  to 
retain  the  limb  in  the  corrected  position.  Tin  or  light  wire  splints 
strapped  upon  the  limb  are  preferable  to  fixed  bandages,  as  they  confine 
the  limb  less. 

Contraction  of  the  hip  as  well  as  of  the  knee  can  ordinarily  be  pre- 
vented from  occurring  by  posterior  splints,  as  the  psoas  contraction  in  a 
functional  affection  of  the  hip  usually  in  time  yields  to  the  weight  of  the 
extended  limb  if  the  patient  is  upright  and  the  knee  prevented  from 
bending  by  a  ham  splint. 

Light  cases  of  functional  affection  of  the  hip  will  be  best  treated  at 
first  by  the  use  of  crutches  and  the  elevated  shoe  to  the  well  foot,  aided 
by  gymnastic  exercises  for  the  limb  of  such  a  character  as  the  patient  can 
endure.  The  elevated  shoe  should  be  lowered  and  removed  gradually, 
and  in  the  same  way  crutches  should  be  shortened  and  replaced  by  a 
cane,  and  finally  all  support  discarded  by  gradual  stages.  The  use  of  a 
hip  splint  will  often  not  be  found  advantageous  on  account  of  its  weight. 
Traction  by  weight  and  pulley  is  rarely  needed,  but  is  sometimes  advis- 
able. Treatment  of  light  cases  of  disease  of  the  knee  and  ankle  may  often 
require  the  temporary  use  of  crutches  and  possibly  fixation  appliances 
for  a  while. 

Much  judgment  is  required  to  determine  what  cases  of  functional 
affection  of  the  hip,  knee,  and  ankle  joints  are  to  be  treated  by  rest,  by 
protection  of  the  limb,  or  by  use. 

Rest  in  bed  is  to  be  avoided  unless  the  patient  is  in  a  marked  neuras- 
thenic condition  needing  quiet.  In  some  instances  confinement  to  bed  is 
unavoidable  during  the  correction  of  deformity. 

In  functional  affections  of  the  limbs  the  strength  of  the  muscles  con- 
trolling the  diseased  joint  should  be  increased  by  graduated  exercise, 
until  the  patient  is  surprised  into  an  unconscious  use  of  a  previously  dis- 
abled limb.  If  removal  of  crutches  or  supports  is  attempted  before  the 
strength  of  the  limb  is  certain,  a  mistake  is  made  and  crutches  will  be 
resumed  by  the  patient.  If  the  strength  of  the  part  has  been  regained, 
use  is  possible  if  the  attention  of  the  patient  expectant  of  suffering  can 
be  diverted  until  the  painless  use  of  the  part  has  been  demonstrated. 

Whatever  the  methods  of  treatment  to  be  instituted,  it  is  absolutely 
essential  that  the  physician  should  have  complete  control  of  the  manage- 
ment of  the  case  without  interference  of  friends  or  relations.  Sometimes 
it  is  therefore  necessary  to  take  the  patient  away  from  home  for  the  time 
being.  In  many  cases  the  home  influence  is  a  most  important  factor  in 
inducing  and  keeping  up  this  condition,  so  that  a  removal  from  these 
influences  is  essential. 


526  ORTHOPEDIC   SURGERY. 

In  cases  in  which  functional  symptoms  are  superadded  to  an  organic 
lesion,  much  skill  and  judgment  are  required  in  treatment. 

In  all  these  varieties  of  functional  affections,  the  principle  of  treat- 
ment is  the  same — temporarily  to  protect  the  affected  part  from  strain 
and  painful  use,  to  improve  the  circulation  and  increase  the  muscular 
strength,  and  as  the  condition  improves  to  train  the  patient  to  the  grad- 
ual resumption  of  the  normal  use  of  the  limb. 


CHAPTER  XVII. 
RICKETS. 

Definition. — Pathological  anatomy. — Occurrence  and  etiology. — Symptoms. — Diag- 
nosis.— Differential  diagnosis. — Prognosis. — Treatment. 

Definition. 

Rickets  is  a  constitutional  disease  which  aff ects  young  children.  Its 
chief  characteristics  are  manifested  in  the  osseous  system,  where  there  is 
a  local  or  general  disturbance  of  the  normal  process  of  ossification,  as  a 
result  of  which  the  epiphyses  become  enlarged  and  the  affected  bones 
become  soft  and  pliable ;  growth  is  delayed  and  deformities  of  a  serious 
character  arise.  The  affection  itself  does  not  belong  to  the  category  of 
surgical  diseases;  but  the  resulting  deformities,  which  demand  strictly 
surgical  treatment,  are  connected  with  the  disease  itself  so  intimately 
that  a  brief  consideration  of  the  subject  is  necessary.  The  affection 
itself  is  so  fully  discussed  in  books  relating  to  the  diseases  of  children 
that  the  reader  can  be  referred  to  them  for  any  detailed  account  of  the 
disease. 

The  disease  is  known  in  English  as  rickets  or  rhachitis.  Other  names 
for  the  affection  are:  morbus  anglicus,  articuli  duplicati,  englische 
Krankheit,  Zwiewuchs,  doppelte  Glieder,  nouure,  rachitisme,  etc. 

Pathology. 

Rickets  occurs  especially  at  the  time  when  the  bone  growth  is  at  its 
maximum  and  its  most  obvious  feature  is  a  defective  calcification  of  the 
bones,  in  consequence  of  which  secondary  changes  occur.  The  normal 
process  of  growth  demands : 

1.  Multiplication  of  cells.  2.  Calcification.  3.  The  formation  of 
medullary  spaces  and  ossification. 

On  the  epiphyseal  line  where  growth  mainly  occurs,  the  process  of 
growth  consists  of  the  apposition  of  cartilage  which  is  absorbed  and  re- 
placed by  bone.  In  rickets  the  pathological  changes  are  most  marked  at 
the  junction  of  the  epiphyses  and  the  shaft.  The  epiphyseal  cartilage, 
which  should  normally  be  a  thin  layer,  in  rickets  appears  as  a  broad, 
reddish-gray,  translucent  cushion,  while  the  whole  epiphysis  is  enlarged. 


528  ORTHOPEDIC    SURGERY. 

There  is  thickening  especially  of  the  transparent  zone  of  the  multi- 
plied cartilage  cells,  the  line  of  calcification  is  thin  or  may  be  wanting  in 
places,  the  formation  of  medullary  spaces  extends  into  the  zone  of  calci- 
fication and  possibly  through  it.  In  the  region  of  the  centres  of  ossifica- 
tion at  the  ends  of  the  diaphysis  there  is  an  increase  of  cartilage  cells 
and  a  lengthening  of  cell  columns,  calcification  occurs  in  scattered  patches 
and  not  at  a  defmite  centre,  vascularity  is  great,  the  formation  of  medul- 
lary spaces  is  increased  but  the  deposit  of  bone  inside  these  spaces  is 
wanting  or  irregular,  its  place  being  taken  by  "osteoid  tissue." 

The  periosteum  of  the  shaft  is  hyperaemic  and  thickened  and  boggy 
and  often  adherent  to  the  bone.  The  subperiosteal  layer,  which  nor- 
mally is  thin  and  scarcely  noticeable,  in  rickets  is  thick  and  appears 
dark  and  like  spleen  pulp.  It  is  a  soft  friable  tissue  called  "  osteoid 
tissue,"  which  consists  of  a  bone  tissue  deficient  in  lime,  with  bone  cells 
often  large,  and  a  fibrillated  ground  substance. 

The  medullary  bone  is  more  hyperaemic  than  normal  medulla  at  this 
age.  The  intercellular  substance  may  show  mucoid  degeneration  or  be 
fluid.  It  does  not  seem  that  lime  is  dissolved  out  of  the  finished  bone, 
but  that  resorption  of  such  bone  in  toto  is  the  important  element. 
Pommer,  Mueller,  and  Virchow  believe  that  resorption  in  rickets  is  not 
increased ;  Kassowitz  and  Ziegler  believe  that  it  is.  Clinically  certain 
cases  of  rapid  softening  seem  to  show  increased  resorption.  In  addition 
to  this  is  the  fact  that  the  fresh  bone  formed  tends  to  contain  a  dimin- 
ished quantity  of  lime.  After  the  active  process  has  ceased  lime  is  de- 
posited in  the  "  osteoid  tissue, "  and  the  result  is  a  thick  and  heavy  bone. 

The  chemical  analysis  of  rhachitic  bone  shows  a  percentage  of  19  to 
53  per  cent  of  ash.  Zalesky  found  in  normal  bone  65  per  cent  of  ash, 
Yon  Bibra  found  in  a  two-months-old  child  65  per  cent  of  ash,  and  in  a 
five-year-old  child  68  per  cent  of  ash. 

The  upright  position  apparently  is  not  necessary  for  the  development 
of  deformity,  which  may  be  caused  by  muscular  contraction  in  the  case 
of  the  long  bones. 

Bodily  weight  and  muscular  action  are  also  likely  to  curve  and  twist 
the  softened  bones,  and  there  is  hardly  any  limit  to  the  deformity  that 
might  result  if  a  reparative  change  did  not  set  in. 

Ossification  after  the  process  is  over  becomes  excessive  and  may  be 
spoken  of  as  petrifaction  or  eburnation,  rather  than  true  ossification. 
Infractions  or  partial  fractures,  with  the  break  on  the  concave  side  of 
the  long  bones,  may  occur.  The  ligaments  become  relaxed  and  stretched, 
and  the  muscles  flabby  from  disuse.  The  spleen  is  ordinarily  enlarged 
and  sometimes  the  liver.  Catarrh  of  the  alimentary  canal  and  bronchi 
are  common  accompaniments. 

In  rickets  of  the  skull  the  meninges  and  brain  may  be  secondarily 
affected. 


RICKETS.  529 

The  other  pathological  changes  are  more  properly  to  be  considered 
under  the  head  of  symptoms. 

Occurrence  and  Etiology. 

Rickets  is  an  affection  occurring  commonly  during  the  first  dentition. 
Cases  of  rickets  are,  however,  described  as  congenital  and  others  as  oc- 
curring during  adolescence. 

Congenital  rickets,  or  foetal  rickets,  is  regarded  as  doubtful  by  such 
authorities  as  Ziegler  and  Vierordt. '  In  the  cases  described  the  periosteal 
lesions  are  absent  and  the  epiphyseal  changes  do  not  agree  accurately 
(Ziegler).  According  to  Vierordt,  most  of  these  cases  were  not  rickets  at 
all,  but  the  cases  of  Fischer,  Winkler,  Borntrager,  Smith,  and  Kumpe 
showed  histological  changes  not  dissimilar  to  rickets.  The  cases  of  Kasso- 
witz  are  not  considered  convincing  by  Vierordt.  Other  cases  have  been 
reported  by  Jacobi,2  Gueniot,3  Henoch,4  Shattock,5  Lewis  Smith6  (with 
skeleton),  Bednar, 7  and  others.  Kaufmann  reports  twelve  cases  of  so- 
called  fcetal  rickets  which  he  would  call  "  chondrodystrophia  fee  talis." 
Whatever  the  technical  pathological  point  of  view  may  be,  a  condition 
closely  resembling  rickets  from  a  clinical  point  of  view  occasionally  arises 
during  foetal  life. 

Rickets  in  Childhood. — The  common  time  of  occurrence  is  early  in 
childhood ;  cases  are  reported  in  which  the  "  rhachitic  rosary  "  was  seen 
as  early  as  the  fourth 8  and  sixth 9  weeks  after  birth.  The  following  col- 
lection of  1,876  cases  will  show  the  tendency  of  the  disease  to  occur  in 
the  first  two  years  of  life. 

1st  yr.  2d  yr.  3d  yr.  4th  yr.  5th  yr.     Over  5. 

Guerin 98  176        35  19        10  5 

Bruenische 20  79        47  7  6          4 

Rittershain 266  154        62  15  7         17 

Ritsche 72  109        25  9       #4 

Baginsky 256  313        63  

710        831       232         50        27         26  + 

Rickets  seldom  begins  before  six  months  or  after  three  years. 

The  rickets   of  adolescence  or  late  rickets  is  a  disease  which  affects 


1  Vierordt:  "Rachitis  und  Osteomalacic" 

2 Jacobi:  Am.  Journ.  Obst.,  November,  1870. 

3 Gueniot:  Rev.  Mens,  des  Mai.  de  l'Enfance,  January,  1884. 

4 Henoch:  "Diseases  of  Children." 

6  Shattock:  Lond.  Path.  Soc.  Trans.,  1881. 
6 Smith:  "Diseases  of  Children." 

7  Quoted  by  Lewis  Smith. 

8 Parry:  Am.  Journ.  Med.  Sci.,  January,  1872. 
9 Gee:  St.  Barth.  Hosp.  Rep.,  vol.  iv. 
34 


530 


ORTHOPEDIC   SURGERY. 


persons  at  about  the  age  of  puberty  9 2  it  is  generally2  associated  with 
albuminuria,  and  its  etiological  relations  are  decidedly  obscure.  The 
physical  signs  are  practically  the  same  as  in  the  rickets  of  early  life, 
except   that   the   epiphyseal   enlargement    is    generally   not    so    great. 

Drewett  reported  a  case  to  the  London 
Pathological  Society  in   1880    in  which 
a  dissection  of  the  skeleton  showed  the 
same  characters  as  in  early  rickets.3 
A  committee  of  the  Pathological  So- 


FiG.  487.  -  Chondrodystrophia  Fcetalis, 
"  Congenital  Rickets." 


Fig.  488.— Rickets  of  Adolescence.    (Glutton.) 


ciety  examining  this  case  reported  the  changes  to  be  characteristic  of 
rickets.     Clutton  has  reported  two  cases4  of  the  sort. 

In  2,595  cases  of  rickets  reported  from  various  authors,  there  were 
1,337  boys  to  1,258  girls. 

Heredity. — The    weight   of    authority5    seems    to    favor    the   view 


1  Lucas  :  Lancet,  June  9th,  1883. 

2Keetly:  Annals  of  Surgery;  Palm:  Practitioner,  xlv.,  1890,  p.  275  ;  Duplay: 
Gaz.  des  Hop.,  1891,  p.  1397  ;  Robert  Jones:  Brit.  Med.  Journ.,  1896,  i.,  341. 

3Maxon:  Guy's  Hospital  Reports,  1878. 

4  St.  Thomas'  Hospital  Reports,  vol.  xiv. 

5 Parker,  Vogel,  and  von  Rittershain:  "Die  Path,  und  Ther.  der  Rachitis," 
Berlin,  1863. 


RICKETS.  531 

that  a  weakness  of  constitution  is  inherited  rather  than  the  disease  as 

such.1 

As  might  be  expected,  the  later  children  of  a  large  family  are  much 
more  liable  to  rickets  thah  their  older  brothers  and  sisters. 

Inasmuch  as  rickets  is  a  disease  of  malnutrition,  the  commonest 
causes  are  to  be  sought  in  the  immediate  surroundings  of  the  patient. 
Broca's  definition  of  it  best  expresses  the  situation  when  he  speaks  of  it 
as  representing,  "  the  ultimate  effects  of  everything  which  interferes  with 
the  nutritive  processes  during  the  rapid  growth  of  infancy." 

Locality. —In  southern  and  central  Europe  the  disease  is#  especially 
prevalent,  particularly  in  the  cities.  In  America  it  is  less  frequent,  and 
in  the  European  cities  it  varies  very  much.  It  is  rare  in  sub-tropical 
climates,  almost  absent  in  the  tropics,  and  is  said  not  to  occur  in  the 
arctic  regions.  Even  in  the  zones  where  it  occurs  ib  is  rare  in  high  alti- 
tudes.    It  is  most  seen  in  cold  moist  climates. 

In  America  the  disease  is  neither  very  prevalent  nor  very  severe,  and, 
except  in  colored  children  or  in  Italians  and  Portuguese,  very  great  de- 
formity is  rare.  The  great  bulk  of  cases  seen  in  the  northern  cities  of 
America  present  essentially  a  mild  type  of  rickets  compared  to  what  is 
seen  in  Europe. 

A  number  of  children  were  taken  at  random  in  one  of  the  poorest 
quarters  of  Boston  and  carefully  examined  for  rickets,  and  the  results 
have  a  bearing  on  the  question  of  etiology.  The  district  was  one  inhab- 
ited by  Italians,  Irish,  and  Portuguese,  and  represented  the  lowest  class 
of  the  population.  One  hundred  children  between  the  ages  of  one  and 
six  were  stripped  and  examined;  60  showed  no  signs  of  rickets,  while  40 
were  more  or  less  rhachitic.  The  following  figures  represent  the  very 
decided  effect  of  nationality : 

Parentage.  Total.  Rhachitic.  Not  Rhachitic. 

Portuguese 24  20  4 

Irish 51  7  44 

Italian 5  3  2 

American 2  0  2 

English 8  5  3 

The  prevalence  of  rickets  among  the  colored  population  in  northern 
cities  is  most  striking,  and  the  disease  is  not  by  any  means  so  common 
in  the  negro  population  of  the  southern  cities.  The  great  susceptibility 
to  rickets  which  is  shown  by  the  inhabitants  of  southern  Europe  has 
never  been  accounted  for. 

Bad  hygienic  influences,  such  as  poor  ventilation,  damp  dwellings, 
crowded  rooms,  etc.,  have  a  very  marked  sway  in  producing  rickets,  and 
this  factor  is  one  which  continental  writers  make  very  prominent. 

1  Jenner  :  Med.  Times  and  Gazette,  1860,  i.,  460. 


532  ORTHOPEDIC   SURGERY. 

In  America,  where  the  conditions  of  life  among  the  poor  are  very 
different,  rickets  is  almost  exclusively  produced  by  improper  feeding. 
Cheadle, '  representing  an  extreme  point  of  view,  stated  that  he  had  seen 
only  one  case  of  rickets  which  arose  in  a  child  suckled  by  a  healthy 
mother,  and  in  this  case  the  mother  became  pregnant  during  lactation. 

Several  theories  as  to  the  causation  of  rickets  have  been  advanced : 
(1)  that  the  proportion  of  lime  in  the  ingesta  was  deficient  or  that  the 
absorption  of  it  was  deficient.  Analyses  of  various  milks  and  food  taken 
by  rhachitics  seems  to  exclude  the  possibility  of  a  deficiency  of  lime 
in  the  ingesta  (Konig,  Forster,  Gorup,  Besanez).  In  cow's  milk  there  is 
more  lime  than  in  human  milk.  Analyses  of  human  milk  from  mothers 
of  rhachitic  children  showed  no  deficit  of  lime  (Seeman,  Pfeiffer). 
Riidel  found  the  lime  in  the  urine  of  rhachitic  children  not  definitely 
different  from  that  of  normal  children,  and  on  giving  them  an  excess  of 
lime  in  their  food  found  it  absorbed  and  excreted  as  well  as  it  was  in 
healthy  children. 

(2)  A  theory  has  been  advanced  that  lactic  acid  is„generated  in  excess 
in  the  intestinal  canal  by  the  fermentation  of  starchy  food  imperfectly 
digested ;  this,  uniting  with  the  lime  of  the  bones,  removes  the  lime  as  a 
soluble  salt  and  acts  also  as  an  irritant  to  the  osteoplastic  tissue. 

This  and  similar  theories  that  the  softening  of  bone  is  due  to  other 
acids  (carbonic  dioxide,  uric  acid,  etc.)  are  as  yet  unsubstantiated. 

Wegner  found  that  small  doses  of  phosphorus  increased  bone  formation, 
while  dosage  of  phosphorus  with  food  poor  in  lime  did  not  prevent  rickets. 
Kassowitz  claimed  similar  changes  from  the  administration  of  phosphorus 
without  modifying  the  diet,  but  his  results  have  been  questioned  (Vierordt). 

The  infectious  theory  of  rickets  is  not  supported  by  proof. 

Another  theory  lays  the  fault  upon  insufficiency  of  fat  and  proteids 
in  the  diet  of  rhachitic  children.  Artificial  farinaceous  foods  contain  a 
very  much  smaller  percentage  of  fat  than  milk  does,  and  the  experience 
at  the  London  Zoological  Gardens  lends  much  weight  to  the  idea  that  the 
deprivation  of  fat  and  proteids  from  the  diet  of  young  animals  is  a  most 
important  factor  in  the  production  of  rickets.  In  menageries,  where 
animals  live  under  highly  artificial  conditions,  rickets  attacks  young  lions 
especially,  and  is  the  cause  of  death  in  a  large  number  of  cases.  Ostriches, 
pheasants,  and  poultry  under  the  same  conditions  have  a  softened  con- 
dition of  the  bones. 

Bad  hygienic  surroundings  and  improper  food  or  wholly  insufficient 
diet  are  not  the  only  factors,  because  thousands  of  children  grow  up 
every  year  under  these  conditions  without  becoming  in  the  least  rhachitic. 

The  subject  of  the  relation  of  syphilis  to  rickets  must  be  passed  over 
very  briefly  as  having  only  an  incidental  interest  in  this  treatise.     The 

1  Brit.  Med.  Journal,  November  24th,  1888,  p.  1145. 


RICKETS.  533 

present  view  rather  regards  syphilis  as  an  indirect  cause  of  rickets  in 
impairing  the  general  constitution.1  The  common  experience  is  to  find 
a  small  proportion  of  syphilitics  among  rhachitic  children. 

Malaria  has  been  claimed  by  Oppenheimer*  as  the  main  cause  of 
rickets,  but  there  is  do  reason  to  take  the  theory  seriously.  Chronic 
tuberculosis  in  the  parents,  as  well  as  debility  from  any  cause  impairing 
the  nutrition,  may  be  the  cause  of  rickets.  Any  exhausting  disease  in 
the  child  may  be  followed  by  rickets,  while  bronchitis  is  too  common  a 
symptom  of  rickets  to  be  considered  its  cause,  as  some  writers  would  do. 
Finally,  in  certain  rare  cases  no  cause  can  be  assigned  for  the  occurrence 
of  the  affection. 

Symptoms. 

The  disease  is  so  often  the  outcome  of  a  long  period  of  ill  health 
that  it  is  difficult  to  say  when  the  rhachitic  symptoms  begin.  Among 
the  commonest  early  symptoms  are  restlessness  at  night,  profuse  sweat- 
ing, especially  of  the  head,  and  constipation  perhaps  alternating  with 
diarrhoea,  but  the  diagnosis  cannot  be  made  from  the  premonitory  symp- 
toms. 

The  belly  becomes  large  and  distended  with  flatus,  and  although  the 
appetite  may  be  unimpaired,  the  child  looks  white  and  pasty  and  loses 
flesh.  At  this  stage  one  may  encounter  the  characteristic  symptom  of 
general  tenderness  of  the  body,  but  many  cases  never  present  this  symp- 
tom. This  tenderness  is  sometimes  confined  to  the  bones  and  is  mani- 
fested only  on  deep  pressure,  while  at  other  times  the  muscles  are  ex- 
quisitely tender,  and  the  gentlest  effort  to  lift  the  child  may  cause  him 
to  shriek  with  pain.     This  symptom  disappears  readily  under  treatment. 

The  so-called  "  paralysis  of  rickets  "  is  at  times  an  accompaniment  of 
this  stage,  and  is  generally  brought  to  the  parent's  notice  by  the  child's 
inability  to  walk  or  sometimes  to  stand.  At  other  times  it  may  be  more 
severe  and  take  the  form  of  inability  to  use  the  arms  as  well  as  the  legs. 
There  is  no  permanent  lesion  of  the  nervous  system  in  these  cases,  and  a 
careful  examination  in  the  recumbent  position  shows  that  the  child's 

JRanke:  Int.  Med.  Cong.,  1881,  vol.  iv.  ;  Cazin  and  Iscovesco  :  Arch.  gen.  de 
MeU,  September,  1887  ;  Lannelongue  :  Soc.  de  Chir.,  1881,  p.  370, 1883,  p.  4  ;  Poncet: 
Bull,  de  la  Soc.  Anatomique,  1874;  Kassowitz:  "Die  Sypli.  als  die  Ursache  der 
Rachitis,"  Int.  Cong.,  London,  1881,  vol.  iv.  ;  Taylor:  "Syphilitic  Lesions  of  the 
Osseous  System  in  Infants  and  Young  Children,"  London,  1875  ;  Parrot:  Bull,  de  la 
Soc.  de  Chir.,  Paris,  1883,  174;  Despres  :  Bull,  de  la  Soc.  de  Chir.,  April  5th,  1883; 
Magitot:  Trans  Int.  Med.  Cong.,  vol.  iv.,  1881;  Capitan  :  Bull,  de  la  Soc.  de  Chir., 
ix.,  322;  Capistrel :  "Cont.  a  1 'Etude  de  l'Etiol.  du  Rachitisme,"  These  de  Lille, 
June  21st,  1883  ;  Gibert :  Soc.  de  Chir.,  1883 ;  Girard  :  Revue  de  la  Suisse  Romande, 
July  5th,  1883  ;  Pini :  Semaine  med. ,  1885,  p.  325  ;  Gaillard  :  France  med. ,  January 
7th,  1886,  p.  14;  Discussion  Int.  Med.  Cong.,  1881,  p.  52,  vol.  iv. 

2Deutsches  Archiv  f.  klin.  Med.,  1881,  xxx. 


534  ORTHOPEDIC   SURGERY. 

muscular  movements  are  but  little  impaired.  The  disability  is  to  be 
attributed  to  the  muscular  weakness  and  the  bone  tenderness,  particularly 
to  a  periosteal  tenderness  at  the  muscular  insertions.1  The  electrical 
reaction  is  normal,  the  reflexes  are  not  affected,  and  recovery  is  certain 
if  the  child  lives.  This  pseudo-paralysis  is  an  early  symptom  of  rickets, 
and  as  a  rule  precedes  any  marked  osseous  change,  which  adds  to  the 
difficulty  of  its  recognition.  The  most  difficult  affection  from  which  to 
distinguish  it  is  the  disability  due  to  simple  weakness  in  non-rhachitic 
children,  but  the  distinction  is  not  one  of  any  practical  importance. 

Fever  is  most  often  absent  or  due  to  some  complication,  such  as  bron- 
chitis. Convulsions  may  occur  at  any  stage  of  the  disease,  especially 
when  there  is  any  tendency  to  craniotabes. 

In  certain  cases  these  symptoms  are  all  so  acute  that  some  writers 
would  make  them  a  separate  class  under  the  head  of  acute  rickets.  Some 
cases  so  reported  belong  to  infantile  scurvy,  in  others  the  anatomical 
lesions  and  the  symptoms  are  the  same  as  in  ordinary  rickets  except  for 
their  greater  severity,  and  they  seem  to  belong  clearly  enough  to  the 
same  group  as  the  slower  cases.2 

Changes  in  the  Bones. — Some  time  after  these  general  premonitory 
symptoms  the  changes  in  the  osseous  system  begin  to  be  evident.  En- 
largement of  the  epiphyses  appears,  especially  at  the  wrists  and  anterior 
ends  of  the  ribs.  Enlargement  of  the  lower  end  of  the  radius  and  ulna 
is  practically  universal,  whereas  enlargement  of  the  lower  end  of  the 
tibia  and  fibula  occurred  in  only  400  out  of  1,000  cases.3  These  enlarge- 
ments do  not  involve  the  joints.  At  the  ribs  one  finds  the  "rosary,"  a 
series  of  bead-like  enlargements  easily  felt  at  the  junction  of  the  carti- 
lages and  the  ribs,  and  a  small  degree  of  epiphyseal  enlargement  is  easily 
detected  here,  and  not  likely  to  be  mistaken  for  anything  else.  When 
these  changes  have  occurred,  the  bones  have  already  softened  and  curva- 
tures of  the  long  bones  may  have  begun.  In  the  deep-seated  epiphyses, 
like  the  hip  and  shoulder,  one  does  not  notice  the  change. 

The  proliferating  layer  between  the  epiphysis  and  the  bone  may  be- 
come so  thick  and  so  soft  that  separation  of  the  epiphysis  and  much 
consequent  deformity  may  occur;  but  such  an  event  is  rare. 

The  forces  that  work  to  produce  deformity  in  the  softened  bones  are 
muscular  action,  gravity,  atmospheric  resistance,  and  the  pressure  ex- 
erted on  bony  structures  by  growing  organs. 

It  will  be  best  to  consider  seriatim  the  changes  which  rickets  produces 
in  the  different  parts  of  the  body. 

In  the  head,  certain  changes  are  so  constant  that  one  depends  much 
on  them  for  the  diagnosis.     The  typical  head  of   rickets  has   a   high, 

!H.  W.  Berg:  N.  Y.  Med.  Rec,  November  16th,  1881. 

2 Gee:  St.  Barth.  Hosp.  Rep.,  xvii.  ;  Barlow:  Med.  Chir.  Trans.,  vol.  lxvi.,  159. 

3 Reeves:  "Pract.  Orthopedics,"  p.  14. 


RICKETS. 


535 


square,  prow-shaped  forehead,  with  a  decided  prominence  of  the  lateral 
parts  of  the  frontal  bones  (frontal  eminences)  and  sometimes  the  parietal 
eminences  as  well.  In  general  the  head  appears  to  be  larger  in  circum- 
ference than  normal.  This  is  due,  when  it  actually  exists,  to  thickening 
of  the  cranial  bones. ' 

The  expression  of  the  face  is  intelligent,  although  the  face  may  show 
the  ill-health  of  the  child,  and  the  superficial  veins  of  the  scalp  and  face 
may  be  enlarged. 

The  anterior  fontanelle,  which  should  normally  close  at  about  the 
eighteenth  month,  remains  widely  open  and  does  not  ossify  until  perhaps 


Fig.  489.—  Rhachitic  Spine.    Enlarged  epiphyses  at  wrist. 


Fig.  490.— Enlarged  Epiphyses  at  Wrist. 


the  third  year  or  even  later.  This,  however,  is  not  enough  to  establish 
the  fact  that  the  child  is  rhachitic  until  the  age  of  two  years  has  been 
reached.  The  posterior  fontanelle  sometimes  remains  open  for  months. 
The  sutures  may  also  remain  open  longer  than  they  should,  and  in  such 
cases,  after  ossification,  they  are  apt  to  show  a  depressed  gutter  of  bone 
where  they  have  been ;  and  such  a  depression  is  not  uncommon  at  the 
site  of  the  closure  of  a  fontanelle.  Sometimes,  however,  prominence  takes 
the  place  of  depression.2 

The  name  craniotabes  is  applied  to  an  abnormal  thinness  of  portions 
of  the  parietal  and  occipital  bones  which  yield  to  gentle  pressure  and 
give  the  sensation  of  crackling  parchment.     The  affection  is  uncommon 

!Rep.  of  Lond.  Path.  Soc,  Lancet,  ii.,  1880,  1017  ;  Patholog.  Soc.  Trans.,  1881, 
Discussion  on  Rickets  ;  "Klinik  der  Padiatrik,"  ii.  Bd.,  1877. 

2  Schwenke  :  "Ueber  denEinfluss  derR.  auf  den  Durchbrucn  des  Milchgebisses," 
Inaug.  Diss.,  Halle,  1886. 


536 


ORTHOPEDIC    SURGERY. 


in  the  mild  degree  of  rickets  seen  in  America.  The  affection,  however, 
occurs  in  simple  rickets. 

Hyperaernia  of  the  brain  and  meninges  may  be  an  accompaniment. 
With  this  hyperemia  comes  the  likelihood  of  hydrocephalus,  either  ex- 
ternal or  internal,  and  the" accompanying  cerebral  changes,  so  that  hydro- 
cephalus becomes  a  complication  of  rickets  which  i3  not  very  rare. 

Deformities  of  the  chest  are  among  the  most  common  produced  by 
rickets  and  they  occasionally  exist  without  any  well-marked  signs  of 
rickets  elsewhere.  It  is  not  unusual  to  see  young  girls  about  the  age  of 
puberty  who  have  discovered  some  inequality  in  the  chest  or  prominence 
of  the  lower  ribs  perhaps,  but  who  present   no  other  signs  of   rickets. 


Fig.  491.— Characteristic  Rhachitic  Head. 


Fig.  492.— Rickets  with  Hydrocephalus. 


In  these  cases  it  seems  reasonable  to  assume  that  a  slight  degree  of  bone 
softening  existed  in  childhood  and  passed  away  without  leaving  any  other 
sign  than  the  chest  malformation. 

Deformities  of  the  chest  are  produced  by  muscular  action  of  the  mus- 
cles connected  with  the  thorax  and  also  by  the  atmospheric  pressure  on 
the  thoracic  walls.  In  a  typical  rhachitic  chest  the  clavicles  are  shorter 
and  more  curved  than  they  naturally  should  be.  The  chest  is  narrow 
and  prominent  in  front ;  it  shows  the  effect  of  lateral  compression,  and 
the  sternum  projects  so  prominently  that  the  name  of  pigeon  breast,  or 
pectus  carinatum,  is  commonly  given  to  it.  The  weakest  part  of  the 
chest  cavity  is  at  the  junction  of  the  ribs  and  cartilages,  and  it  is  here 
that  the  chief  yielding  takes  place  and  the  ribs  allow  themselves  to  be 
pressed  in  laterally,  while  the  sternum  is  pushed  forward.  At  other  times 
the  ribs  are  pushed  together  laterally  while  the  sternum  is  pressed  back. 
This  leaves  a  depression  where  the  sternum  should  be  and  is  spoken  of 
as  "funnel  chest."     Again,  one  side  may  yield  more  than  the  other  and 


RICKETS. 


537 


a  prominence  of  the  front  part  of  the  ribs  on  one  side  of  the  sternum 
may  be  the  only  deformity.  A  transverse  depression  in  the  chest  known 
as  Harrison's  sulcus  also  occurs  in  the  typical  cases.  It  is  most  evident 
just  below  the  nipples  and  has  been  thought  to  be  due  to  the  action  of 
the  diaphragm  at  its  attachment.  It  is,  however,  above  that  level.  The 
softening  of  the  ribs  is  said  to  occur  (Vierordt)  after  the  changes  in  the 
skull  and  before  the  changes  in  the  extremities.  The  prominence  of  the 
abdomen,  which  is  almost  universal  in  well-marked  rickets,  adds  to 
the   deformity   of   the  chest  by   the   elevation   of    the   lower   ribs,    on 


Fig.  493.— Deformity  of  Spine  in  Rickets. 


account  of  the  underlying  distention.  When  the  abdominal  distention 
disappears,  this  flaring  of  the  lower  part  of  the  ribs  is  sometimes  left 
behind. 

Kyphosis. — A  very  common  deformity  of  the  spinal  column  due  to 
rickets  is  a  bowing  backward ;  a  gradual  bowlike  curve  (involving  the 
dorsal  and  lumbar  regions) .  It  is  a  uniform  flexion  of  the  whole  column 
and  is  most  prominent  at  the  junction  of  the  dorsal  and  lumbar  regions. 
This  attitude  seems  the  result  of  a  long-continued  sedentary  position 
with  a  weakness  and  tenderness  of  the  muscles  which  fail  to  hold  the 
spine  in  the  erect  position.  Rhachitic  children,  as  a  rule,  learn  to  walk 
late,  and  this  peculiar  flexion  seems  a  persistence  and  exaggeration  of  the 
position  which  the  spine  naturally  assumes  in  young  babies,  who  are 
propped  up  in  the  sitting  position.  The  prominence  of  the  vertebral 
spines  at  this  place  is  often  quite  sharp  and  simulates  Pott's  disease 
most  closely. 


538  ORTHOPEDIC   SURGERY. 

A  rhachitic  spine  should  be  flexible  to  passive  manipulation,  however 
much  it  may  be  curved,  but  occasionally  much  muscular  irritability  ac- 
companies this  condition,  and  at  times  cases  are  seen  of  rhachitic  curva- 
ture of  the  spine  in  which  the  curved  part  of  the  spine  is  inflexible  to 
manipulation.  In  those  cases,  when  the  child  is  laid  on  its  face  (as 
described  under  Pott's  disease)  and  lifted  by  its  legs  to  test  the  flexi- 
bility of  the  column,  the  spine  is  rigid. 

Scoliosis  is  a  common  deformity  due  to  rickets,  which  has  already 
been  considered. 

Lordosis  is  the  third  of  the  common  deformities  due  to  rickets,  and 
gives  rise  to  a  characteristic  attitude,  the  importance  of  which  is  much 
overlooked. 

The  Rhachitic  Attitude. — The  attitude  of  a  child  affected  with,  well- 
marked  rickets  is  characteristic.  It  exists  in  most  marked  cases  of 
knock-knee  and  bow  legs  and  sometimes  in  a  less  degree  with  milder 
grades  of  the  affection.  The  child  stands  with  the  legs  apart,  the  thighs 
flexed  and  the  knees  bent,  the  back  is  arched  and  the  shoulders  are  thrown 
back.     The  cause  of  this  attitude  has  never  been  quite  clearly  established. 

It  is  undoubtedly  in  a  measure  the  persistence  of  the  infantile  attitude, 
the  position  which  children  assume  who  are  just  learning  to  walk.  Chil- 
dren with  rickets  have  weak  muscles  as  well  as  weak  bones,  and  the 
condition  of  such  a  child  approaches  that  of  an  infant,  in  large  measure ; 
hence  he  stands  and  walks  with  the  least  expenditure  of  muscular  force. 
This  explains  certain  cases.  Another  factor  is  the  protuberant  abdomen 
the  weight  of  which  the  child  seems  to  counterbalance  by  leaning  back- 
ward. 

Deformity  of  the  pelvis  is  induced  by  rickets  because  the  body  weight 
is  borne  by  a  bony  arch  which  has  lost  part  of  its  supporting  power,  and 
bends  under  weight.  These  pelvic  deformities  have  only  a  significance 
in  regard  to  obstetric  surgery,  they  occasion  no  trouble  or  noticeable  de- 
formity in  themselves ;  but  in  females,  when  pregnancy  comes  on,  their 
existence  is  a  matter  of  the  gravest  importance.  The  subject  is  fully 
treated  in  all  books  upon  obstetrics. 

Except  in  very  severe  cases,  the  arm  bones  are  not  seriously  curved. 
The  curvatures  follow  no  especial  rule,  but  generally  they  are  an  exag- 
geration of  the  normal  curves  of  the  bones.  The  curvature  of  the  arm 
bones  may  be  due  to  creeping  or  to  lifting  the  child  continually  by  taking 
hold  of  the  forearm  in  one  place,  but  as  a  rule  is  the  result  of  muscular 
action. 

Coxa  vara  may  exist  in  the  hips.  The  condition  has  been  already 
described. 

The  rhachitic  deformities  of  the  legs  are  of  such  importance  that  they 
will  be  considered  under  the  separate  headings  of  knock-knee  and  bow 
legs. 


RICKETS. 


539 


Flat-foot  is  a  very  common  accompaniment  of  rickets.  The  affection 
is  considered  under  flat-foot. 

In  general,  the  skeleton  is  not  only  deformed  but  stunted,  and  persons 
who  have  rickets  severely  in  childhood  do  not  reach  average  size  in  adult 


Fig.  494.— Attitude  of  Severe  Rickets,  Showing 
Lordosis  and  Rotation  of  Pelvis. 


Fig.  495.— Extreme  Deformity  from  Rickets. 


life  as  a  rule.  The  osseous  deformities,  as  a  rule,  persist  to  a  certain 
extent  through  life.  Notably  is  this  true  of  the  shape  of  the  skull  and 
the  chest. 

Laryngismus  stridulus  is  an  occasional  complication  of  rickets. ' 
Important  symptoms  relate  to  the  eruption  of  the  teeth ;  not  only  are 
they  late  and  irregular,  but  they  are  imperfect  generally,  and  unable  to 
resist  decay.  On  the  average  the  first  tooth  appears  about  the  ninth 
month,  and  not  only  is  the  interval  between  the  teeth  longer,  but  the 
order  of  appearance  is  often  abnormal.  The  first  dentition  does  not  end 
on  the  average  until  the  third  year.  The  teeth  may  present  the  charac- 
teristics of  the  so-called  "Hutchinson's  teeth." 

Latent  rickets  is  a  term  of  very  doubtful  utility ;  it  is  used  chiefly  in 


1  Money  :  Lancet,  January,  1889;  Goodhardt :  "Dis.  of  Children,"  p.  645. 


540 


ORTHOPEDIC   SURGERY. 


speaking  of  cases  in  which  only  one  symptom  or  one  group  of  symptoms 
becomes  evident,  and  it  does  not  seem  to  mark  out  any  one  type  of  the 
disease,  although,  of  course,  it  must  necessarily  be  applied  only  to  mild 
cases ;  but  it  may  be  assumed  that  the  existence  of  localized  rickety  bone 
changes  is  perfectly  possible,  and  such  a  theory  is  needed  to  explain  cer- 


Fig.  496.  —Extreme  Curvature  of  Bones. 


tain  cases  of  bow  legs  in  children,  e.g.,  when  no  symptoms  of  general 
rickets  are  present;  and  there  is  this  local  softening  of  the  leg  bones 
which  is  not  likely  to  be  due  to  any  other  than  a  rhachitic  cause. 


Diagnosis. 

The  diagnosis  in  fully  developed  rickets  is  simple;  but  when  the 
affection  is  beginning,  its  recognition  may  be  attended  with  difficulty. 

In  beginning  rickets,  certain  symptoms  are  suggestive;  these  are; 
restlessness  and  sweating  at  night,  and  especially  universal  tenderness 
when  acute  articular  rheumatism  is  not  manifestly  present.  In  well- 
marked  cases  the  diagnostic  points  are  the  epiphyseal  enlargement  of  the 
ends  of  the  long  bones,  especially  the  wrists  and  the  sternal  ends  of  the 
ribs;  the  prow-shaped  head;  the  deep,  small  chest  and  the  big  belly. 
Delayed  dentition  and  an  anterior  fontanelle  open  long  beyond  the  proper 
time  are  equally  characteristic.  If  the  disease  has  advanced  still  further, 
one  often  finds  curvature  of  the  bones  of  the  legs  and  arms. 

Delayed  dentition  is  so  important  a  sign  in  the  diagnosis  of  rickets 
that  it  deserves  especial  attention.  If  no  teeth  have  appeared  by  the 
ninth  month  the  child  is  very  likely  rhachitic,  and  if  no  teeth  appear  at 
the  end  of  the  twelfth  month  the  child  is  almost  certainly  rhachitic ;  but 
the  latter  are  extreme  cases  and  exceptional  ones.  In  general  the  de- 
layed appearance  of  the  teeth  should  direct  attention  to  the  possible  ex- 


RICKETS.  541 

istence  of  rickets.  The  second  symptom,  which  is  of  equal  value,  is 
the  delayed  closure  of  the  anterior  fontanelle.  If  this  remains  open 
until  the  age  of  two  years,  there  is  little  doubt  that  the  child  has  rickets. 
It  should  normally  close  about  the  eighteenth  or  twentieth  month. 

Delay  in  learning  to  walk  should  also  excite  suspicion  of  the  presence 
of  rickets.  The  cough  and  general  tenderness  so  often  associated  with 
rickets  are  apt  to  obscure  the  affection,  inasmuch  as  they  tend  to  mislead 
parents  and  physician.  « 

Differential  Diagnosis. 

There  are  certain  symptoms  found  at  times  in  both  syphilis  and 
rickets.  These  are  "Hutchinson's  teeth,"  craniotabes,  and  flexible 
bones,  which  are  occasionally  seen  in  syphilis.  Most  cases  of  congenital 
syphilis  present  no  resemblance  to  rickets  and  are  not  to  be  confused 
with  it.  The  differential  diagnosis  can  be  made  on  the  general  charac- 
ters of  the  two  affections. 

Acute  articular  rheumatism  can  be  distinguished  from  rickets  by 
the  presence  of  high  temperature,  joint  swelling  and  tenderness,  partic- 
ularly acute  at  the  joints,  while  the  tenderness  of  rickets  is  more  often 
general  or  limited  to  the  epiphyses.  Among  young  children  rickets  is 
much  the  more  common  of  the  two  diseases. 

The  condition  induced  by  malnutrition  is  sometimes  hard  to  distin- 
guish from  rickets.  Feeble  children  with  large  heads  and  flabby  muscles 
learn  to  walk  late,  and  this  very  fact  often  suggests  the  presence  of 
rickets  and  the  existence  of  rhachitic  paralysis.  In  general  the  diag- 
nosis can  be  made  by  the  absence  of  the  characteristic  signs  of  rickets ; 
but  it  is  not  to  be  made  off-hand,  but  with  very  great  care,  and  at  times 
it  may  be  necessary  to  wait  for  time  and  treatment  to  determine  whether 
the  child  is  suffering  from  the  early  stage  of  rickets  or  not. 

From  Pott's  disease  rhachitic  spinal  curves  are  sometimes  not  easily 
distinguished.  Young  children  a  few  months  old  are  not  infrequently 
brought  for  examination  on  account  of  a  prominence  in  the  back  and  a 
great  deal  of  crying  in  being  lifted  or  handled.  At  the  junction  of  the 
lumbar  and  dorsal  regions  a  prominence  may  be  present  involving  several 
vertebrae,  which  may  or  may  not  be  obliterated  when  the  child  lies  on  its 
face,  and  is  lifted  by  its  feet  from  the  table.  Sometimes  the  constitu- 
tional evidences  of  rickets  are  so  marked  that  the  diagnosis  is  clear; 
Pott's  disease,  when  it  occurs  in  young  children,  begins  often  in  this 
location  and  in  this  way.  The  writers  have  seen  cases  in  which  doubtful 
kyphoses  of  the  same  characteristics  have  been  kept  under  observation 
and  treatment,  and  one  case  has  proved  to  be  rhachitic,  while  another 
developed  into  clearly  marked  Pott's  disease.  Rhachitic  kyphosis  is 
more  common  than  Pott's  disease  in  children  under  eighteen  months,  and 


542 


ORTHOPEDIC   SURGERY. 


although  the  presence  of  rickets  does  not  rigidly  exclude  the  possibility 
of  Pott's  disease,  yet  when  the  general  signs  of  rickets  are  present,  it  is 
safe  to  assume  that  in  most  cases  the  kyphosis  will  disappear  under 
treatment.     In  doubtful  cases  time  alone  will  clear  up  the  question. 

Pigeon  breast  due  to  Pott's  disease  is  often  found  when  there  is  a 
large  deformity  in  the  dorsal  region  of  the  spine,  and  the  bodies  of  the 


Fig.  497.— Rhachitic  Curvature,  Simulating  Pott's  Disease. 


vertebrse  have  given  way.     Beading  of  the  ribs  is  absent  and  it  occurs 
only  after  the  knuckle  in  the  spine  is  very  evident. 

Prom  osteomalacia  occurring  in  children  rickets  can  hardly  be  differ- 
entiated during  life. 

Prognosis. 

When  the  disease  is  left  to  itself  it  generally  runs  its  course,  and 
after  a  decided  degree  of  bony  deformity  has  occurred  the  process  of 
bone  softening  is  spontaneously  arrested,  and  the  bones  harden  in  their 
deformed  condition. 

Spontaneous  arrest  of  the  disease  may  take  place  at  any  stage  without 
treatment,  but,  as  a  rule,  in  severe  cases  not  before  a  serious  degree  of 
bony  deformity  has  been  produced.  A  fatal  issue  may  be  brought  about 
by  the  complications  of  the  disease.  In  untreated  cases  the  prognosis  is 
unfavorable  in  those  which  have  begun  at  an  early  age ;  when  the  disease 
is  treated  efficiently  the  prognosis,  as  to  life,  is  always  favorable  unless 
some  serious  complication  is  present,  and  the  disease  is,  as  a  rule,  easily 
amenable  to  treatment. 


RICKETS.  543 

The  arrest  of  the  disease  at  an  early  stage  is  most  important,  as  it  is 
highly  desirable  that,  if  possible,  deformity  should  be  avoided. 

The  kyphosis  above  alluded  to  disappears  under  proper  treatment. 
Lateral  curvature  is  permanent  when  not  treated.  The  complications, 
craniotabes,  laryngismus  stridulus,  bronchitis,  diarrhoea,  and  paralysis, 
improve  as  the  general  condition  becomes  better,  and  finally  disappear. 
As  a  rule  the  bony  deformities,  such  as  epiphyseal  enlargement,  diminish 
with  growth,  but  remain  through  life  to  a  certain  degree.  It  may  be 
mentioned  that  in  reading  treatises  on  rickets  by  English  writers,  the 
American  reader  must  make  allowances  for  the  greater  severity  of  the 
disease  in  the  English  climate. 

Treatment. 

The  preventive  treatment  of  rickets  consists  simply  in  the  proper 
feeding  of  any  child  whose  surroundings  are  not  positively  bad.  It  has 
been  seen  that  rickets  almost  never  develops  without  sufficient  dietetic 
cause,  and  its  prevention  consists,  therefore,  in  giving  suitable  food  to 
each  child. 

For  what  this  food  should  be  the  reader  is  referred  to  works  on  the 
diseases  of  children.  In  addition  to  this  diet  it  is  desirable  to  give  to 
rhachitic  children  of  over  six  months  meat  juice  or  raw  beef  in  small 
quantities  and  orange  or  lemon  juice. 

The  earlier  in  the  disease  the  case  is  seen  the  more  important  is  the 
regulation  of  the  food.  In  cases  in  which  the  process  is  nearly  ended, 
it  matters  little  what  the  child  eats  except  in  so  far  as  it  influences  his 
general  condition. 

Drug  treatment  is  manifestly  secondary  in  importance  to  careful  regu- 
lation of  the  diet  and  hygiene. 

A  remedy  much  advocated  in  the  treatment  of  rickets  is  phosphorus, 
and  especially  is  this  extolled  by  German  writers  who  ascribe  to  it  almost 
a  specific  action.  It  is  given  in  doses  of  T-i-¥  to  T^  of  a  grain  three 
times  a  day,  and  in  two  or  three  weeks  it  is  said  that  marked  improve- 
ment may  be  seen. '  It  is  administered  in  cod-liver  oil,  but  is  also  avail- 
able in  pill  form,  or  it  may  be  dissolved  in  sweet  almond  oil 2  or  alcohol 
diluted  with  glycerin. 

Lime  is  a  remedy  very  much  advocated  in  the  treatment  of  rickets, 
and  it  is  generally  given  in  combination  with  phosphoric  acid,  either  as 
powdered  phosphate  of  lime,  or  the  syrup  of  the  hypophosphites,  or 
syrup  of  the  lacto-phosphate.  Its  use  rests  rather  upon  a  theoretical 
than  an  empirical  basis,  and  one  is  apt  to  be  disappointed  in  its  working 
as  a  drug.     It  is,  however,  desirable  to  administer  lime  in  the  food  in 

1  Toeplitz  and  Kassowitz  :  Cent,  f .  Chir. ,  1887,  No.  10. 
sZeit.  f.  klin.  Med.,  1883,  vii. ,  36. 


544  ORTHOPEDIC   SURGERY. 

some  way  during  convalescence;  but  the  administration  of  lime  water 
seems  of  little  use  unless  there  is  reason  to  believe  that  the  contents  of 
the  stomach  are  unduly  acid.  Parrish's  chemical  food  is  an  acceptable 
and  efficient  way  of  giving  lime. 

Cod-liver  oil  is  of  use  both  alone  and  in  conneation  with  other  treat- 
ment. One  -method  of  administration  is  to  have  the  oil  rubbed  into  the 
legs  and  abdomen  each  night  with  the  warm  hand.  The  method  is  not 
objectionable  if  the  oil  is  carefully  washed  off  in  the  morning. 

The  use  of  wine  or  spirits  in  small  quantities  is  advisable  in  the  case 
of  children  whose  general  condition  is  poor  and  whose  circulation  is 
feeble. 

Finally  one  finds  a  long  list  of  drugs  which  are  advocated  by  various 
writers. 

The  complications  of  rickets  are  to  be  treated  much  as  if  they  were 
independent  affections. 

Hygiene  and  General  Surroundings. — Rhachitic  children  should  be 
bathed  daily,  preferably  in  salted  water,  and  rubbed  vigorously.  Warm 
woollen  clothing  should  be  worn  and  they  should  go  out  daily.  Especial 
care  should  be  taken  to  keep  them  in  sunny,  well-ventilated  rooms ;  their 
meals  should  be  regular,  and  they  should  be  obliged  to  eat  slowly.  The 
bowels  should  be  watched  and  kept  regular;  and  every  care  should  be 
paid  to  keeping  the  child's  general  condition  as  good  as  possible  in  every 
way.  The  seashore  hospitals,  now  established  in  Italy,  France,  Ger- 
many, and  America,  provide,  with  proper  nursing,  air,  and  food,  the  best 
prophylactic  against  rickets.  In  some  of  the  large  cities  in  Italy,  insti- 
tutions similar  to  those  in  America  known  as  "  day  nurseries  "  have  been 
provided  for  the  daily  reception  and  treatment  of  rhachitic  children,  with 
proper  arrangements  for  bathing  and  fresh  air.  Marked  improvement  is 
reported  in  the  cases  treated  in  these  institutions. 

The  discussion  of  the  operative  and  mechanical  treatment  of  rickets 
will  be  taken  up  under  the  head  of  knock-knee  and  bow  legs. 

Osteomalacia. — Osteomalacia  is  a  process  somewhat  similar  to  rickets, 
also  occasioning  softening  of  the  bones,  occurring  most  often  in  adults 
but  occasionally  in  children.  It  is  the  disease  at  one  time  spoken  of  as 
"  senile  rickets." 

Of  the  cause  of  osteomalacia  nothing  definite  is  known.  It  occurs 
generally  in  women,  often  in  connection  with  pregnancy „  It  is  far  more 
frequent  in  certain  localities  than  in  others.  The  characteristic  change 
in  the  process  is  a  softening  of  the  bones  similar  to  that  in  rickets,  but 
the  pathological  condition  is  different.  There  is  absorption  of  lime  salts 
beginning  first  at  the  medullary  cavity  and  proceeding  outward;  the 
epiphyses  are  not  notably  affected.  In  rickets,  it  will  be  remembered, 
the  chief  pathological  changes  occur  at  the  epiphyses.  In  osteomalacia 
the  medulla  resembles  that  in  infancy  in  gross  appearance,  due  to  an 


RICKETS.  5  1  5 

infiltration  of  round  cells,  loss  of  fat,  and  a  hyperemia.'  By  the  con- 
tinuance of  the  absorptive  process  the  cortical  bone  becomes  spongy  and 
decalcified,  and  in  the  severest  cases  there  may  remain  little  but  marrow 
and  periosteum.2  Of  course,  in  this  condition  the  bones  may  be  de- 
formed to  a  very  great  degree.  The  milder  forms  of  the  affection  are, 
of  course,  much  more  common  than  these  extreme  grades.  Most  of  the 
pathologists  are  of  the  opinion  that  in  osteomalacia  the  layer  of  "  osteoid 
tissue  "  results  from  decalcification,  while  in  rickets  a  similar  layer  rep- 
resents a  new  growth  deficient  in  lime  salts.  The  periosteum  is  likely  to 
be  thickened  and  vascular. 

Spontaneous  fractures  may  occur  as  si  symptom  of  osteomalacia,  but 
other  causes  of  such  fractures  exist  in  the  condition  known  as  osteopsathy- 
rosis which  is  often  hereditary.  In  osteomalacia  when  such  fractures 
occur  union  may  occur  or  false  joints  may  be  the  result.  In  all  sponta- 
neous fractures  union  may  of  course  occur  at  a  vicious  angle. 

The  most  familiar  bony  deformity  in  osteomalacia  is  distortion  of  the 
pelvis,  the  leg  bones  may  bend  and  bow  legs  or  genu  valgum  may  be 
found.  The  thorax  is  flattened  laterally  and  fractures  of  the  ribs  may 
occur.  The  changes  in  the  spine  have  been  alluded  to  in  Chapter  III. 
The  condition  of  osteomalacia  has  been  reported  in  children.3 

A  treatment  proposed  and  carried  out  in  a  number  of  cases  consists 
in  the  removal  of  the  ovaries.  Phosphorus  is  said  to  be  of  much  value 
in  certain  cases. 

»Ziegler:  "Path.  Anat.,"vol.  ii. 

■  Warren,  J.  C.  :  "Surg.  Pathology,"  p.  598. 

3Eehn:  Jahrb.  f.  Khde.,  1878,  xii.,  100,  and  1883,  xix.,  171;  Siegert :  Munch, 
med.  Woch.,  xlv.,  November  1st,  1898;  Griffiths:  Tr.  Am.  Assn.  Physicians,  1896, 
xi.,  121. 

35 


CHAPTER  XVIII. 

KNOCK-KNEE  AND   BOW   LEGS. 

Knock-knee.  — Occurrence  and  etiology.  — Symptoms. — Diagnosis.  — Prognosis. — 
Treatment.  — Expectant.  —  Mechani  cal. — Operative.  — Bow  Legs.  —  Occurrence.  — 
Causation. — Symptoms. — Diagnosis.  —  Prognosis.  — Treatment.  — Expectant.  — 
Mechanical. — Operative. 

Knock-knee. 

Knock-knee,  or  genu  valgum,  is  the  name  applied  to  an  internal  angu- 
lar prominence  of  the  knee,  in  which  the  bones  of  the  leg  form  an  ab- 
normal lateral  angle  with  the  bones  of  the  thigh,  and  this  angle  opens 
outward. 

This  condition  is  also  known  in  English  as  in- knee;  in  Latin  as  genu 
introrsum ;  in  German  as  Knickbein,  X-bein,  Backerbein,  Ziegenbein, 
Kniebohrer,  Knieng,  and  Schemmelbein ;  in  French  as  genou  cagneux, 
genou  en  dedans,  and  in  Italian  as  ginocchio  torto  all'  indentro. 

Occurrence  and  Etiology. — The  deformity  is  one  of  common  occur- 
rence, but  not  so  common  as  bow  legs.  In  7,900  cases  of  surgical  dis- 
ease in  children  coming  to  the  Out-Patient  Department  of  the  Boston 
Children's  Hospital  there  were  only  218  cases  of  knock-knee,  while  there 
were  427  cases  of  bow  legs.  In  6,400  cases  of  surgical  disease  in  chil- 
dren treated  at  the  New  York  Orthopedic  Hospital  and  Dispensary 
there  were  270  cases  of  knock-knee  and  400  cases  of  bow  legs;  and  in 
general  this  relative  frequency  holds  good.  Both  deformities  affect  boys 
more  often  than  girls. 

Knock-knee  is  a  deformity  which  becomes  evident  in  early  childhood 
or  at  adolescence.  In  rare  cases  it  has  been  noted  at  birth,  but  it  appears 
for  the  most  part  shortly  after  the  children  learn  to  walk,  although  by 
no  means  is  its  appearance  necessarily  delayed  until  that  time — for  the 
deformity  is  sometimes  seen  in  infants  in  arms;  but  always  in  these 
cases  it  is  associated  with  general  rickets.  Its  regular  appearance, 
then,  is  at  one  of  two  distinct  periods :  between  the  ages  of  two  and  four, 
or  between  the  ages  of  twelve  and  eighteen.  Exceptional  cases  occur  at 
any  age. 

Knock-knee  occurring  in  the  first  period  named  is  almost  always  as- 
sociated with  general  rickets,  and  no  obscurity  exists  as  to  its  cause,  and 
this  is  spoken  of  by  many  writers  as  genu  valgum,  rhachiticum,  to  distin- 


KNOCK-KNEE   AND   BOW   LEGS. 


547 


guish  it  from  the  form  occurring  at  puberty,  which  is  spoken  of  as  genu 
valgum  staticum  sive  adolescentium.     Many  efforts  have  been  made  to 


identify  this  later  form  also  with  rickets,  as  by  Mikulicz  and  others,  who 
would  consider  it  a  local  rhachitic  process,  a  form  of  "latent  rickets." 


54:8 


ORTHOPEDIC   SURGERY. 


The  form  of  knock-knee  occurring  in  adolescence  especially  affects  per- 
sons whose  occupation  compels  them  to  be  most  of  the  time  in  a  standing 
position,  and,  as  a  rule,  those  affected  are  individuals  of  feeble  physique. 

Other  cases  of  knock-knee  are  produced  as  a  late  result  of  muscular 
paralysis.  Fractures  about  the  joint  and  destructive  ostitis  are  also 
causes  of  knock-knee  in  exceptional  cases. 

How  these  pathological  factors  find  their  clinical  expression  in  an 
angular  deformity  of  the  knee  will  be  considered  in  the  following  section. 

Mechanical  Production  of  Knock-knee. —The  normally  formed  human 
being  in  the  upright  position  stands  with  a  certain  amount  of  knock-knee. 


Fig.  499.— Severe  Knock-knee. 


Fig.  500.— Severe   Knock-knee,  with   Outward 
Rotation  of  Tibia. 


The  femurs  form  an  angle  of  15°  with  each  other  and  sometimes  more, 
and  as  a  result  of  this  oblique  direction,  the  inner  condyle  of  the  femur 
must  be  longer  than  the  outer.  This  is  evident  from  a  glance  at  the 
figure.  This  excess  of  length  must  vary  with  the  width  of  the  pelvis 
and  the  obliquity  of  the  femurs.  Clark  estimated  that  the  internal  con- 
dyle of  the  femur  was  normally  longer  than  the  external  by  a  quarter  of 
an  inch,  and  Holden  estimates  it  as  one-half  an  inch  longer  under  normal 
circumstances. 

The  chief  cause  of  the  deformity  seems  to  be  a  static  one,  except  in 
those  early  cases  due  to  rickets  in  which  weight  has  not  been  borne  upon 
the  feet.  Here  its  cause  lies  in  an  unequal  growth  of  the  epiphysis  of 
the  femur  or  in  a  bend  of  the  lower  part  of  the  shaft  of  the  femur  or  the 
upper  part  of  the  tibia  produced  by  great  softness  of  the  bone  and  mus- 
cular action  pulling  upon  the  bone  and  causing  it  to  curve. 

When  a  normally  formed  person  stands  erect  with  the  heels  together, 
if  a  plumb  line  be  dropped  from  the  head  of  the  femur  it  will  be  seen 


KNOCK-KNEE   AND   BOW   LEGS. 


549 


to  fall  outside  of  the  cenlre  of  the  knee-joint;    and  this  will  happen  to  a 
greater  extent  in  the  female  than  in  the  male. 

It  is  therefore  evident  that  the  external  condyle  of  the  femur  and 
the  corresponding  facet  of  the  tibia  transmit  more  body  weight  than  do 
the  corresponding  internal  articular  surfaces,  because  the  centre  of  grav- 
ity lies  outside  of  the  centre  of  the  joint. 

To  maintain  an  erect  position  with  the  feet  together  requires,  there- 
fore, muscular  action.     If  the  standing  position  is  to  be  maintained  for  a 

long  time,  or  for  a  short 
time  in  the  case  of  chil- 
dren or  feebly  developed 
adults,  the  instinctive 
disposition  is  to  substi- 
tute  ligamentous  for 
muscular  support.  This 
can  be   accomplished  by 


Fig.  501.— Rhachitic  Knock-knee. 


FIG.  502.— Slight  Knock-knee  (Chief- 
ly on  Left)  with  Flat-foot. 


keeping  the  knee  extended  and  separating  and  everting  the  feet.  It  is 
the  attitude  assumed  by  children  learning  to  walk  and  by  tired  adults. 
In  this  way  the  weight  comes  upon  the  knee-joint  laterally,  and  muscular 
effort  is  not  needed  to  keep  the  joint  rigid  in  the  lateral  plane;  for  that 
is  accomplished  by  the  ligaments.  This  attitude  is  often  spoken  of  as 
"the  attitude  of  rest." 

Prom  this  position  more  weight  than  before  is  transmitted  through 
the  external  condyle,  and  less  through  the  internal  one.  If  angular  de- 
formity takes  place,  finally  all  the  weight  is  transmitted  through  the 
external  condyle. 


550  ORTHOPEDIC   SURGERY. 

Two  results  may  follow  from  this :  stretching  of  the  internal  lateral 
ligament  and  atrophy  of  the  external  condyle. 

The  stretching  of  ligaments  when  subject  to  undue  tension  is  too 
familiar  a  pathological  process  to  require  comment.  The  atrophy  of  bone 
which  is  subjected  to  pressure  and  strain  has  been  established  clearly 
enough  by  Arbuthnot  Lane. ' 

These  factors  tend,  then,  to  produce  and  increase  angular  deformity 
at  the  knee.  As  the  external  condyle  shrinks  and  the  ligament  lengthens, 
the  angle  between  the  bones  of  the  thigh  and  the  bones  of  the  leg  in- 
creases, and  with  each  increase  the  body  weight  acquires  better  leverage 
and  more  power  to  do  harm  to  the  yielding  joint. 

Although  the  mechanical  forces  just  alluded  to  are  competent  to  pro- 
duce severe  knock-knee,  the  presence  of  rickets  makes  the  condition 
much  worse,  for  it  not  only  softens  the  bones,  but  relaxes  the  ligaments 
and  weakens  the  muscles.  It  is  easy  to  see,  therefore,  how  much  this 
process  would  aid  in  producing  the  deformity  of  knock-knee,  not  only  at 
the  joint,  but  in  the  femur  and  the  tibia,  by  allowing  their  shafts  to  bend 
above  and  below  the  joint,  and  so  making  the  deformity  excessive. 

Flat-foot  ordinarily  coexists.  Sometimes  it  must  stand  in  a  causative 
relation  to  knock-knee ;  sometimes  it  is  more  the  result  than  the  cause, 
but  commonly  they  are  both  the  results  of  the  same  faulty  attitude,  as- 
sumed as  a  result  of  muscular  fatigue  and  weakness.  Flat-foot  is  moi  ^ 
easily  produced  than  knock-knee,  and  is  much  more  common. 

It  is  proper  to  recognize  the  class  of  cases  when  the  femur  is  appar- 
ently normal,  but  the  articulating  surfaces  on  the  head  of  the  tibia  are 
oblique.  This  is  considered  as  the  common  cause  of  the  deformity  by 
some  writers. 

In  still  a  third  class  of  cases  the  deformity  is  due  not  so  much  to 
primary  joint  obliquity  as  to  a  bend  in  the  diaphysis  of  the  femur  or  the 
tibia  just  above  or  just  below  the  joint.2 

There  are,  then,  three  bony  deformities  likely  to  be  found  in  cases 
of  knock-knee,  viz. : 

(a)  Difference  in  the  size  of  the  condyles  of  the  femur. 

(b)  Inequality  in  the  articular  facets  of  the  tibia. 

(c)  Bending  of  the  diaphyses  of  the  bones  above  or  below  the  joint. 
In  severe  cases  the  tibia  is  found  to  be  rotated  outward. 

The  internal  ligaments  are  hypertrophied,  and  the  muscles  and  ten- 
dons on  the  inner  aspect  of  the  leg  are,  of  course,  stretched.  The  patella 
lies  farther  outside  than  it  should  do.  In  some  it  may  be  seen  that  the 
outward  rotation  of  the  tibia  is  so  marked  that  a  sort  of  compensatory 
inversion  of  the  feet  has  been  acquired  almost  to  the  condition  of  varus 
to  aid  in  keeping  balanced. 

xLane:  Guy's  Hosp.  Rep.,  vol.  xxviii.       2Arch.  f.  klin.  Chir.,  1879,  xxiii. 


KNOCK-KNEE   AND   BOW   LEGS. 


551 


The  deformity  is  due  to  the  yielding  of  ligaments  and  bone  at  the 
knee-joint.  It  occurs  in  connection  with  general  rickets  and  in  cases 
in  which  general  rickets  cannot  be  demonstrated  but  in  which  undue  soft- 
ness of  bones  and  ligaments  must  have  existed. 

Mikulicz  would  find  the  cause  in  hyperextension  of  the  tibia  and  con- 
sequent exaggerated  external  rotation  of  that  bone. 

Symptoms, — Subjective  symptoms  in  knock-knee  are  almost  always 
absent.     Children  and  adults  tire  more  easily  than  they  should  when 


Fig.  503.— Child  with  Loose  Ligaments  Standing 
"at  Ease." 


Fig.  504.— Same  Child  Standing  "at  Attention." 
(Children's  Hospital  Report.) 


they  have  knock-knee,  and  sometimes  pain  and  sensitiveness  are  com- 
plained of  over  the  internal  lateral  ligament  of  the  knee ;  as  a  rule  those 
with  knock-knee  are  clumsy  and  have  a  poor  sense  of  balance.  But  this 
is  not  commonly  noticed.  In  young  children  with  knock-knee  and  active 
rickets  locomotion  is  generally  difficult,  while  in  adult  cases  there  is  less 
difficulty  in  walking,  even  in  severe  cases,  than  would  be  expected  from 
the  degree  of  the  deformity. 

In  the  standing  position  it  is  noticed  that  the  knees  are  unduly  promi- 
nent on  the  inside  aspect  of  the  leg,  and  that  the  tibiee  diverge  so  that 


552 


ORTHOPEDIC   SURGERY. 


the  feet  are,  perhaps,  only  a  few  inches  apart,  or  again,  in  severe  cases,  a 
considerable  distance.  In  cases  in  which  the  angular  deformity  is  very 
great,  the  patients  find  the  easiest  position  for  standing  is  with  one  knee 
behind  the  other,  so  that  in  this  way  the  feet  may  be  brought  together. 

If  the  child  stands  with  the  feet  together  one  knee  is  generally  a 
little  hyperextended  and  the  other  slightly  flexed  so  that  they  appar- 
ently come  together. 

Hyperextension  of  one  or  both  knees  and  outward  rotation  of  the 
tibia  are  common  accompaniments  of  knock-knee. 

The  gait  of  a  patient  with  double  knock-knee  is  distinctive.  Inas- 
much as  the  knees  overlap  when  the  feet  are  together,  some  means  must 
be  adopted,  on  the  patient's  part,  to  prevent  the  knees  from  knocking 


Fig.  505.— Axis   of   a   Normal   Leg,  and 
of  one  Affected  with  Knock-knee. 


Fig.  506.— Inequality  of  the  Condyles,  shown  in  Outline 
in  a  Case  of  severe  Knock-knee. 


against  each  other  as  he  carries  one  leg  forward  past  the  other  in  walk- 
ing. If  he  walked  naturally,  the  knee  that  was  behind  would  hit  against 
the  front  knee  and  stop  progression.  This  can  be  avoided  by  throwing 
his  body  to  one  side  while  he  abducts  the  opposite  leg,  and  so  carries 
it  past  the  stationary  leg  without  knocking  the  knees  together.  This 
must  be  repeated  at  each  step,  so  that  the  gait  is  a  rolling  one,  consisting 
of  a  series  of  slight  lurches,  which  are,  however,  not  nearly  so  marked 
as  in  bow-legs  or  congenital  dislocation  of  the  hip;  while  what  is 
particularly  noticeable  is  the  outward  throw  of  the  leg  when  it  is  being 
brought  forward. 

The  gait  is,  moreover,  slightly  modified  by  the  fact  that  in  severe 
cases  the  thighs  and  consequently  the  knees  are  slightly  flexed.  "  Toe- 
ing in  "  is  common,  even  in  the  slighter  grades. 

When  the  deformity  is  unilateral,  the  limp  is  much  less  marked.  The 
affection  of  the  gait  is  generally  very  slight  in  these  cases.  Lateral  cur- 
vature is  sometimes  induced  by  the  unilateral  deformity,  especially  as 


KNOCK-KNEE   AND   BOW    LEGS. 


553 


the  knock-knee  is  likely  to  occur,  as  we  have  seen,  in  patients  whose 
muscular  development  is  feeble. 

On  manipulation,  the  knee-joint  is  often  movable  in  a  lateral  plane 
through  an  arc  of  several  degrees.     In  these  cases  the  defoimity  is,  of 


Fig.  507.— Showing  Disappearance  of  Deformity  when  Knee  is  Flexed. 

course,  increased  when  weight  is  put  upon  the  affected  leg,  so  that  in 
walking  and  standing  it  reaches  its  maximum. 

The  angular  deformity  disappears  when  the  knee  is  flexed  to  a  right 
angle,  except  in  cases  in  which  the  chief  twist  is  in  the  tibia.  But  if  the 
knee  be  flexed  while  the  hip-joint  is  still  extended,  the  deformity  does 
not  entirely  disappear,  though  it  is  very  much  diminished. 

The  practical  point  is,  that  as  the  deformity  is  most  severe  when  the 
leg  is  in  the  extended  position,  all  mechanical  treatment  applied  to  the 


554 


ORTHOPEDIC   SURGERY. 


correction  of  knock-knee  must  be  to  the  fully  extended  leg,  for  when 
apparatus  allows  the  knee  to  flex,  it  is  imperfect,  and  loses  a  part  of  its 
efficiency.  When  the  leg  is  fully  flexed  the  inequality  in  the  length  of 
the  condyles  is  most  evident,  as  seen  in  outline  from  the  anterior  surface 
of  the  thigh.  This  may  be  registered  by  shaping  a  lead  strip  to  the 
lower  surface  of  the  femur  when  the  knee  is  fully  flexed,  and  drawing 
an  outline  on  paper  from  the  lead  strip,  which  should  be  stiff  enough  to 
keep  its  shape  (see  Figs.  506  and  508). 

Secondary  Deformities.  —  Beside  lateral  curvature  and  flat-foot  there 
is  seen  at  times  a  condition  of  the  foot  approaching  varus  in  certain  ad- 
vanced cases  of  knock-knee  in  which 
the  deformity  is  severe  and  a  con- 
tinual effort  is  made  to  invert  the 
feet  and  so  bring  the  support  nearer 
the  centre  of  the  body.  By  this 
means  a  permanent  inversion  of  the 
front  part  of  the  foot  may  be  ac- 
quired (see  Fig.  519). 

Occasionally  one  sees  a  combi- 
nation of  knock-knee  and  bow  legs 
in  the  same  subject. 


Fr 


508.— Tracing  of  Case  of    Knock-knee  with 
Outline  of  Condyles. 


Fig.  509.— Case  of  Knock-knee,  Showing  also 
the  Tracings  of  the  Legs  at  an  Interval  of  Four 
Years  with  no  Treatment. 


Measurement  of  the  Deformity. — The  simplest  and  most  reliable 
method  of  registration  is  to  have  the  patient  sit  upon  a  sheet  of  brown 
paper  with  the  legs  extended  and  the  feet  pointing  upward ;  and  then, 
with  a  pencil  held  perpendicularly  to  the  paper,  to  trace  the  outline  of 
the  legs.  No  other  method  can  give  so  accurate  an  idea  of  the  degree 
and  character  of  the  deformity  present,  or  can  afford  so  delicate  a  means 
of  watching  and  recording  the  progress  of  the  case. 

Diagnosis The  diagnostic  points  which  mark  the  affection  known  as 

knock-knee  are  an  inward  angular  deformity  at  the  knee  which  disap- 
pears on  flexion  of   the  leg  upon  the  thigh.     There  is  also  in  the  latter 


KNOCK-KNEE   AND   BOW   LEGS.  555 

position  to  be  noted  a  relative  prominence  of  the  internal  condyle  of  the 
femur  in  nearly  all  cases. 

In  children  the  large  proportion  of  all  cases  are  rhachitic  and  static, 
while  in  adults  the  purely  static  cause  must  be  assigned.  It  is  not  in 
general  justifiable  to  assume  rickets  as  the  cause  of  knock-knee  in  cases 
in  which  there  are  no  distinctive  signs  of  rickets. 

Paralytic  knock-knee  occurs  only  in  severe  grades  of  paralysis.  Its 
diagnosis  is  evident  from  the  wasted  and  contracted  condition  of  the 
paralyzed  limb. 

Knock-knee  from  destructive  disease  of  the  knee-joint  is  a  result  of 
severe  tumor  albus  and  not  of  the  lighter  grades. 

Traumatic  knock-knee  is  of  two  kinds:  (a)  Resulting  from  oste- 
otomy for  genu  varum  and  over-correction  of  the  deformity;  (b)  re- 
sulting from  fractures  of  the  condyles  of  the  femur  or  of  the  articular 
facets  of  the  tibia,  which  are  liable  to  cause  lateral  malposition  of 
the  knee. 

Prognosis. — In  severe  cases  it  is  evident  that  so  much  harm  has  been 
done  already,  and  the  bones  have  come  into  such  faulty  apposition,  that 
spontaneous  improvement  is  not  to  be  expected.  Children  with  a  slight 
degree  of  knock-knee  which  is  not  progressive  will  probably  outgrow  it 
without  any  treatment  if  in  vigorous  health.  But  if  the  deformity  is 
moderate  or  severe,  the  chances  are  strong  that  the  affection  will  remain 
stationary  or  more  probably  will  become  worse  as  time  goes  on,  unless 
active  treatment  is  begun. 

Treatment. — The  treatment  of  knock -knee  falls  into  three  divisions : 
(I.)  Expectant;   (II.)  Mechanical;   (III.)  Operative. 

I.  The  expectant  method  of  treatment  relies  upon  nature's  efforts  to 
repair  the  deformity ;  efforts  which  are  aided  on  the  part  of  the  surgeon 
by  keeping  the  child  off  of  its  feet  to  a  greater  or  less  extent,  and  by 
constitutional  treatment  and  by  massage.  In  mild  cases  there  is  a  ten- 
dency to  outgrow  the  deformity,  but  this  tendency  is  at  a  great  disad- 
vantage mechanically ;  nor  is  it  a  safe  proceeding  to  wait  for  this  sponta- 
neous cure  in  any  marked  case  of  knock-knee.  The  difficult  question  in 
the  whole  matter  is  to  decide  which  cases  can  be  left  to  themselves — a 
question  which  cannot  be  answered  categorically. 

An  argument  for  the  spontaneous  outgrowth  of  knock-knee  is  found 
by  some  writers  in  the  rarity  of  adult  cases  which  present  themselves  at 
clinics.  Gibney1  observed  in  six  years  276  cases  of  genu  valgum  at  the 
Hospital  for  the  Ruptured  and  Crippled ;  and  255  were  in  children  below 
fourteen  years  of  age.  This  scarcity  of  cases  in  older  persons  is  noted 
in  all  hospital  clinics,  but  it  is  not  altogether  a  trustworthy  observation 
upon  which  to  depend,  because  the  class  of  adults  who  would  be  likely 

1  Gibney  :  N.  Y.  Med.  Journ.,  November  29th,  1884. 


556 


ORTHOPEDIC   SURGERY. 


to  come  to  such  clinics  would  attach  but  little  importance  to  a  deformity 
which  practically  caused  them  no  inconvenience. 

Whitman1  attacked  the  same  question  from  a  slightly  different 
standpoint  by  counting  the  proportion  of  persons  with  knock-knee  among 
adult  males,  taken  consecutively  as  he  met  them  in  the  streets  of  Boston. 
In  2,000  adult  males  he  observed  32  cases  of  knock-knee,  and  although 
it  is  impossible  to  state  even  approximately  the  proportion  of  knock-knee 
children,  he  calls  attention  to  the  fact  that  it  is  not  likely  to  be  larger 
than  this.     From  his  observations,  therefore,  he  would  conclude  that,  there 


Fig.  510.— Manipulation  in  the  Treatment  of  Knock-knee. 

was  not  a  very  great  tendency  in  children  to  outgrow  this  deformity. 
Noble  Smith,  several  years  ago,  reached  practically  the  same  conclusion, 
making  observation  upon  adults  among  the  English  artisan  class. 

It  is  said2  that  the  tendency  of  slight  knock-knee  is  very  strong 
toward  recovery  if  the  body  weight  is  taken  off  of  the  affected  joint.  It 
may  be  remarked  that  no  treatment  is  harder  to  carry  out  practically  than 
this. 

When  the  expectant  method  is  chosen  in  rhachitic  knock  -knee,  the 
child  should  at  once  be  put  upon  the  constitutional  treatment  for  rickets. 
If  the  knock-knee  is  merely  the  outcome  of  a  feeble  general  condition, 
the  patient  should  be  most  carefully  looked  after  in  the  matter  of  hygiene, 
and  tonic  treatment  and  gymnastics  should  be  given,  the  aim  of  which 
should  be  to  strengthen  the  leg  muscles.  As  much  as  possible  the  pa- 
tient should  be  kept  off  of  the  feet,  and  a  change  to  country  air  is  capable 
of  effecting  great  local  improvement  in  feeble  children. 

The  legs  should  be  rubbed  and  manipulated  each  night.     The  rubbing 


JN.  Y.  Med.  Record,  July  30th,  1887. 

-  Liverpool  Med.-Chir.  Journ.,  January,  1887,  119. 


KNOCK-KNEE   AND   BOW   LEGS. 


557 


should  be  the  same  as  that  described  under  infantile  paralysis,  and  the 
manipulation,  in  cases  of  knock-knee,  should  be  directed  to  the  gentle 
correction  of  the  deformity  by  repeated  mild  manual  pressure.  With 
one  hand  the  manipulator  presses  the  knee  outward  while  with  the  other 
he  presses  the  lower  end  of  the  tibia  inward.  Even  with  a  very  slight 
degree  of  force  a  certain  yielding  can  be  felt  in  the  direction  of  improve- 
ment, and  then  the  pressure  should  be  relaxed  and  the  limb  allowed  to 
resume  its  first  position.  This  manipulation  should  be  repeated  many 
times,  continuing  each  pressure  only  a  few 
seconds.  Nor  should  it  ever  be  done  forcibly 
or  long  enough  to  make  tho  child  cry.  This 
manipulation  faithfully  carried  out  is  an  im- 
portant adjuvant,  not  only  of  expectant  but 
of  mechanical  treatment. 

But  little  harm  is  done  in  applying  splints 
to  a  child  who  might  possibly  improve  with- 
out them,  but  a  great  deal  of  harm  may  be 
done  by  allowing  the  deformity  to  increase 
because  splints  are  not  applied.  In  no  case 
should  expectant  treatment  be  considered 
when  the  child  is  not  under  sufficiently  close 
observation  to  be  seen  every  few  weeks,  and 
to  have  tracings  taken  to  determine  whether 
the  deformity  is  improving  or  is  stationary. 

II.  Mechanical  Treatment.  —  Treatment 
by  apparatus  aims  at  the  gradual  correc- 
tion of  the  deformity,  commonly  by  making 
counter-pressure  against  the  internal  condyle 
to  prevent  the  further  giving  way  of  the  knee 
and  to  pull  it  outward  to  a  fixed  point  fur- 
nished by  an  outside  upright.  Upon  this 
principle  all  modern  apparatus  is  constructed. 

Another  method  which  partakes  largely 
of  the  expectant  plan  is  one  spoken  of   by 

Eushton  Parker,  which  the  writers  have  tried  experimentally.  It 
is  based  upon  the  interdependence  of  flat-foot  and  knock-knee,  which 
suggests  the  treatment  of  knock -knee  by  correcting  the  flat-foot,  either 
by  the  device  of  Mr.  Thomas,  who  raises  the  inner  side  of  the  foot 
by  sloping  off  the  sole  of  the  boot  toward  the  outer  side,  or  by  some 
of  the  various  forms  of  sole  plate  which  elevate  the  arch  of  the  foot, 
and  so  induce  a  more  correct  position  in  standing.  Practically  it  is 
possible  to  improve  the  condition  of  flat-foot  very  much  while  the  knock- 
knee  becomes  worse  or  remains  stationary.  The  plan  of  treatment  is  not 
one  which  can  be  relied  upon. 


Fig.  511.— Bow-leg  of  Right  Leg, 
Knock-knee  and  Flat-foot  on  Left. 


558 


ORTHOPEDIC   SURGERY. 


In  children  in  whom  the  change  known  as  eburnation  has  succeeded 
rickets,  the  bones  are  so  hard  and  unyielding  that  it  is  almost  hopeless, 
by  means  of  such  mild  traction  as  can  be  exerted,  to  pull  the  knee  back 
into  place.  Whether  or  not  this  eburnation  is  present  is  often  a  difficult 
matter  to  decide,  and  one  is  obliged  to  depend  upon  the  age  of  the  child 
and  the  resistance  offered  by  the  bones  on  manual  pressure.  In  general 
terms,  it  is  not  probable  that  mechanical  treatment  will  be  of  use  after 
the  age  of  four  years  has  been  reached  except  in  slight  cases ;  nor  is  os- 
teotomy or  osteoclasis  likely  to  be  considered  before  that  time.       Un- 


FIG.  512.  FIG.  513. 

Figs.  512  and  513.— Knock-knee.    Mechanical  treatment  for  one  and  one-half  years. 

der  this  age  in  moderate  degrees  of  deformity  the  outlook  is  good  with 
mechanical  treatment,  and  the  younger  the  patient  the  better  the  outlook. 

The  aim  of  mechanical  treatment  is  to  cause  atrophy  of  the  internal 
condyle,  with  overgrowth  of  the  external  one,  so  that  the  plane  of  the 
knee-joint  may  once  more  become  normal.  Simply  to  stretch  the  exter- 
nal lateral  ligaments,  without  altering  the  relation  of  the  condyles,  would 
result  in  a  laterally  movable  joint. 

Former  orthopedic  methods  are  exemplified  by  methods  of  recum- 
bency, a  method  which  has  practically  become  obsolete. 

In  the  ambulatory  treatment  of  the  affection  the  form  figured  has 
been  in  use  for  some  years  at  the  Children's  Hospital,  and  has  proved, 
itself  efficient  in  practical  use.  It  is  a  light  steel  rod  attached  below 
to  a  steel  sole  plate  and  jointed  at  the  ankle.  It  runs  up  the  outside  of 
the  leg  as  far  as  the  trochanter,  and  then  the  rod  is  bent  backward  and 
upward,  as  the  figure  shows,  to  lie  against  the  upper  part  of  the  buttock 
and  to  serve  as  an  arm  by  which  the  legs  can  be  everted  if  the  child  toes 
in  in  walking.  Or  the  shaft  may  be  carried  up  to  the  trochanter  and 
finished  in  a  curved   horizontal  arm  following  the  ilium,   with  a  joint 


KNOCK-KNEE   AND   BOW   LEGS. 


559 


■^  *>,«  -hm  The  knee  is  drawn  upon  by  a  square  leather  pad, 
S»  I  'shift  opposite  the  anee.  Tho  upper  ends  of  the  ap- 
™  atus  should  be  buckled  together  posteriorly  by  two  straps,  one  eon- 
neetg  the  tips  of  the  posterior  arms,  and  sometimes  another  may  be 
needed  running  across  the  lower  ab- 
domen, connecting  the  shafts;  by 
lengthening  and  shortening  these 
straps  it  is  evident  that  any  de- 
sired degree  of  inversion  or  e version 
of  the  feet  may  be  produced.  Often 
the  posterior  strap  alone  is  all  that 
is  needed. 


Fig.  515. 


FIG.  514.-Outside  Splints  for  Knock-knee. 


KG.  516. 
Figs.  515  and  516.-Knock-knee  Cured  in  Three 
Years  by  the  use  of  Simple  Outside  Upright.  A 
good  average  result. 

A  cheaper  and  simpler  apparatus  is  mentioned  by  Noble  ^con- 
sisting of  two  straight  outside  wooden  splints,  attached  together  at  the 
p    by  a  band  to  encircle  the  posterior  half  of  the  pel™,  and  below 
strapped  to  the  ankles  by  a  broad  piece  of  webbing      They  run  down  the 
outside  of  the  legs  and  the  knees  are  pulled  out  to  them. 

There  is  no  advantage  in  carrying  the  outside  uprights  to  a  rigid 

waist  band  as  is  done  sometimes.  ^nmhencv 

In  the  older  methods  of  treatment,  long  continued,  with  "cumbenoy 

in  bed,  successful  cures  have  been  reported  in  patients  much  older  than 


560  ORTHOPEDIC    SURGERY. 

would  be  subjected  to  mechanical  treatment  in  the  practice  ot  modern 
orthopedic  surgeons. 

III.  Operative  Treatment. — The  modern  operative  treatment  of  knock- 
knee  is  comprised  under  the  simple  operations  of  osteotomy  and  osteo- 
clasis. Division  of  the  outer  ligaments  and  tendons  of  the  knee  and 
Delore's  redressement  force  belong  to  the  surgery  of  the  past. 

Osteotomy. — The  operation  consists  in  the  division  of  part  of  the  bone 
by  the  chisel,  and  the  completion  of  the  procedure  by  fracture  of  the 
partly  divided  bone. 

The  operations  all  have  much  the  same  aim  and  differ  only  in  detail ; 
their  object  is  one  of  these  three  things: 

(1)  Separation  of  the  internal  condyle  and  its  displacement  upward. 

(2)  Section  of  the  upper  end  of  the  tibia  and  perhaps  the  fibula. 

(3)  Section  of  the  femur  above  the  condyles. 

The  operation  of  osteotomy  performed  with  antiseptic  precautions  is 
not  one  which  is  attended  with  any  special  risk.  Macewen,  in  1884,  had 
done  osteotomy  for  genu  valgum  820  times, '  with  5  deaths ;  and  in  no  case 
was  •  death  to  be  considerd  as  directly  traceable  to  the  operation — the 
patients  dying  of  pneumonia,  measles,  etc.  Collecting  the  cases  of 
other  British  surgeons  he  had,  with  his  own  820,  1,384  cases  of  knock- 
knee  operated  upon  by  his  method,  with  3  deaths  due  to  operation, 
2  of  which  were  caused  by  septicaemia  and  the  cause  of  the  third  is  not 
stated. 

Accidents  from  carefully  performed  osteotomy  have,  however,  been 
reported.  Howard  Marsh 2  wounded  the  anastomotica  magna  artery  in 
performing  Macewen' s  operation,  and  a  few  days  later  was  obliged  to  cut 
down  on  it  and  tie  it.  McGill 3  reported  a  case  in  which  the  popliteal 
artery  was  divided  and  had  to  be  ligatured.  Gibney4  reported  a  case  of 
severe  hemorrhage  from  the  bone  and  speaks  of  it  as  the  only  severe  hem- 
orrhage that  he  has  ever  seen  from  the  operation.  He  also  mentions 
another  case  of  which  he  knew,  in  which  the  anastomotica  artery  was 
wounded.  Fatal  bleeding  has  resulted  from  the  operation, 6  and  Langton0 
reports  death  after  amputation  of  the  thigh  on  account  of  gangrene,  con- 
sequent upon  ligation  of  the  popliteal  artery  which  had  been  punctured 
by  a  sharp  spicule  of  bone  projecting  from  the  lower  fragment. 

The  external  peroneal  nerve  has  been  divided,  and  doubtless  a  number 
of  accidents  which  have  occurred  have  never  been  reported;  but  the 
writers  in  a  large  number  of  cases  in  their  own  experience  and  that  of 
. i — 

'Macewen:  Lancet,  September  27th,  1884. 

2Brit.  Med.  Journ,,  1884,  i.,  665;  Lancet,  May  17th,  1884,  p.  891. 

3 McGill:  Lancet,  May  17th,  1884. 

4N.  Y.  Med.  Journal.  December  6th,  1884. 

6Phila.  Med.  News,  November  1st,  1884. 

6  Lancet,  March  29th,  1884. 


KNOCK-KNEE    AND    BOW    LEGS. 


r><;i 


FIG.  517. 


Roberts1  Elastic  Traction  Krace 
for  Knock-knee. 


their  colleagues,  have  known  of  no  accident  in  the  performance  of  Mac- 
ewen's  osteotomy. 

In  525  operations  by  Ogston's  method  there  were  13  hemorrhages 
of    considerable  severity,    while  in  580 
osteotomies  done  by  Macewen's  method 
there  were  only  2  cases  of  such  bleeding. ' 

Macewen  says  that  hemorrhage  which 
occurs  in  the  performance  of  the  opera- 
tion as  described  by  him  is  due  to  one 
of  the  following  mistakes :  the  use  of 
too  broad  an  instrument;  not  cutting 
the  posterior  part  of  the  bone  with  the 
chisel  pointed  forward  and  outward,  but 
alloAving  the  chisel  to  point  backward; 
holding  the  osteotome  loosely  and  letting 
it  slip  during  the  cutting. 

The  osteotome  should  be  marked  on 
one  side  of  the  blade  with  lines  one- 
quarter  of  an  inch  apart  to  show  how 
deeply  the  edge  has  penetrated.  It  is 
very   convenient    to   have   two  breadths 

of  osteotome,  one  three-eighths  of  an  inch  wide,  the  other  five-eighths 
or  three-quarters  of  an  inch  wide.  They  should  be  about  six  inches 
long;  but  if  only  one  width  is  practicable  it  should  be  half  an  inch 
wide." 

The  operation  of  Macewen  has  superseded  all  other  operations  for  the 
correction  of  knock-knee. 

Macewen's  operation  is  performed  as  follows:  the  patient's  leg  is 
rendered  aseptic ;  the  patient  lies  on  his  side  with  the  leg  extended,  the 
outer  side  of  the  knee  resting  on  a  sand-bag.  The  skin  and  underlying 
tissues  are  then  divided  with  a  knife  over  the  point  of  division  of  the 
bone,  or,  what  is  more  simple,  the  chisel  is  driven  through  the  sound 
skin  into  the  bone  without  any  incision.  This  diminishes  the  bleeding 
and  simplifies  the  operation.  The  use  of  an  Esmarch  bandage  is  unnec- 
essary. 

The  point  selected  for  operation  is  at  the  inner  side  of  the  thigh,  half 
an  inch  above  the  abductor  tubercle  of  the  femur.  The  osteotome  is 
driven  into  the  bone  with  the  blade  at  right  angles  to  the  long  axis  of 
the  femur,  and  by  successive  blows  with  the  mallet  the  operator  cuts 
nearly  through  the  whole  thickness  of  the  bone.  The  osteotome  is  likely 
to  become  wedged  very  firmly  unless  the  precaution  is  taken  to  move  the 
handle  of  the  chisel  laterally  after  each  blow.     In  this  way  alone  can  one 


■Brit.  Med.  Journ.,  June  80th,  1888,  p.  13*3 
36 


2  Lancet,  April  21st.  1880. 


562 


ORTHOPEDIC    SURGERY. 


cut  from  the  front  to  the  back  of  the  bone,  for  driving  the  chisel  straight 
through  in  one  line  accomplishes  but  little.  When  the  chisel  has  disap- 
peared to  a  depth  indicating  that  three-quarters  of  the  bone  has  been 
divided,  it  should  be  withdrawn  and  an  attempt  made  to  fracture  the 
thigh  by  gentle  bending.  If  this  cannot  be  done,  the  osteotome  should 
cut  further,  for  the  common  mistake  is  a  failure  to  divide  the  anterior  and 
posterior  borders  of  the  femur. 

When  the  bone  has  broken,  manipulation  should  be  avoided  except  to 
put  the  leg  in  a  corrected  position,  and,  after  an  aseptic  dressing  has  been 
applied,  a  plaster-of -Paris  bandage  should  be  put  on  to  hold  the  leg  in  a 


Fig.  518.— Macewen's  Osteotomy  for  Knock-knee. 

corrected  position.  Slight  paiu,  if  any,  follows  the  operation  and  there 
should  be  no  fever.  No  change  of  dressing  is  needed ;  the  plaster  may 
be  removed  in  three  or  four  weeks,  and  in  six  weeks  or  less  the  patient 
allowed  to  stand  on  the  limbs. 

Hahn,  in  an  article  on  the  treatment  of  genu  varum  and  valgum,  ad- 
vocates the  performance  of  osteotomy  on  the  outer  as  well  as  on  the  inner 
side  of  the  leg ;  in  this  way  he  thinks  that  he  obtains  greater  precision  in 
the  location  of  the  fracture  than  in  chiselling  the  outer  side  of  the  femur 
alone.1 

The  corrected  position  of  the  bone  is  equally  good  whether  the  inci- 
sion is  made  on  the  outer  or  the  inner  side  of  the  shaft. 

The  result  of  osteotomy  at  the  point  of  division  of  the  bone  was 
shown  in  a  specimen  described  by  Dr.  A.  T.  Cabot 2  some  years  ago.     He 

1  Berliner  Klinik  f.  10.  April,  1889. 

2  Boston  Med.  aad  Surg.  Journal,  February  16th,  1883,  p.  154. 


KNOCK -KNEE   AND   BOW   LEGS. 


563 


had  performed  a  Macewen  operation  and  the  child  died  in  six  weeks  of 
typhoid  fever.  On  the  outer  side  of  the  bone  the  line  of  the  shaft  was 
well  preserved;  but  on  the  inner  side  the  compact  wall  of  the  shaft  had 
been  driven  down  into  the  cancellated  tissue.  In  the  centre  the  lower 
fragment  was  impacted  into  the  upper,  which  locking,  of  course,  resulted 
in  great  firmness.  There  was  but  slight  callus  formation  and  only  a  thin 
layer  of  bone  under  the  periosteum 
on  the  outer  side. 

Macewen' s  operation  is  easier 
to  perform  than  any  other  and  is 
applicable  to  nearly  all  cases;  it 
is  so  far  removed  from  the  joint 
that  one  avoids  injury  to  ligaments 
and  synovial  membrane,  and  yet 
the  line  of  section  is  near  enough 
to  the  point  of  abnormal  deviation 
t©  enable  the  deformity  to  be  cor- 
rected by  straightening  the  limb. 

The  chief  operation  upon  the 
condyles  is  Ogston's. 

In  the  performance  of  Ogston's 
operation,  a  knife,  which  is  small 
and  sharp-pointed,  is  entered  about 
two  inches  above  the  adductor  tu- 
bercle of  the  femur,  exactly  in  the 
middle  of  the  inner  surface  of  the 
thigh,  and  is  then  passed  down- 
ward and  outward  across  the  front 
of  the  condyles  until  the  point 
reaches  the  groove  between  the 
condyles,  which  is,  of  course,  with- 
in the  cavity  of  the  joint.  The 
knife     is    then    withdrawn,   being 

made  to  cut  down  to  the  bone  on  its  way  out.  A  narrow-pointed  saw  is 
then  introduced  through  the  incision  and  passed  down  under  the  patella 
until  its  point  can  be  felt  in  the  intercondyloid  groove.  The  bone  is 
sawed  nearly  through  with  short  quick  strokes  until  the  posterior  surface 
of  the  bone  is  nearly  reached.  The  saw  is  then  taken  out  and  the  limb 
straightened.  An  osteotome  may  be  used  instead  of  a  saw.  Except  for 
very  severe  cases  this  operation  has  been  superseded  by  Macewen' s. 

Thiersch1  raised  a  formidable  objection  to  Ogston's  operation  which 
applies  equally  well  to  all  similar  procedures.     He  called  attention  to 


Fig.  519.— Severe   Knock-knee,    showing    Espe- 
cially the  Inversion  of  the  Feet. 


London  Med.  Rec,  June  15th,  1878. 


m 


ORTHOPEDIC   SURGERY. 


the  fact  that  the  interruption  of  the  epiphyseal  cartilage  might  easily  in- 
terfere with  the  growth  of  that  part  of  the  bone.  Poore,  of  New  York, 
saw  a  case  in  which  this  mishap  had  actually  occurred.  Two  years  after 
an  Ogston'  s  operation  the  left  knee  began  to  bend  outward  and  walking 
became  difficult.1 

Sometimes  when  the  deformity  lies  chiefly  in  the  head  of  the  tibia, 
the  operation  of  osteotomy  might  be  performed  there  either  alone  or  in 
connection  with  femoral  osteot- 
omy. The  removal  of  a  wedge  of 
bone  is  hardly  necessary  from 
either  the  femur  or  tibia  in  cases 
of  knock-knee. 


FIG.  520.— Position  of  Patient  with  severe  Knock- 
knee  in  Walking. 


Fig.  521.— Same  Case  after  Macewen's  Osteotomy. 


At  the  Boston  Children's  Hospital  the  Macewen  operation  is  now 
performed  to  the  exclusion  of  almost  every  other. 

Osteoclasis. — The  forcible  fracture  of  bone  by  instrumental  or  man- 


1  Poore  :  "  Osteotomy  and  Osteoclasis,"  New  York,  1884,  p.  100  ;  C.  T.  Poore  and 
others:  N.  Y.  Med.  Record,  August  13th,  1881;  Little:  "In-Knee,"  Longmans  and 
Green,  London. 


KNOCK-KNEE    AND   BOW   LEGS.  565 

ual  means  in  knock-knee  is  decidedly  inferior  to  osteotomy,  inasmuch 
as  it  lacks  the  precision  of  that  method ;  more  splintering  occurs,  and 
rupture  of  the  external  ligaments  and  epiphyseal  separation  are  apt  to 
occur,  as  in  redressement  force.  Jt  is,  therefore,  better  to  limit  the  use 
of  osteoclasis  to  the  correction  of  bow  legs,  where  the  instrumental  or 
manual  force  can  be  applied  to  the  shaft  of  a  long  bone. 

The  Collin  osteoclast,  however,  breaks  the  bones  with  such  precision 
that  osteoclasis  for  genu  valgum  has  been  advocated,  especially  in  France. 
L>elens,  who  had  given  up  osteoclasis  for  Macewen's  osteotomy,  returned 
to  the  performance  of  osteoclasis  after  seeing  Collin's  new  osteoclast. 
Rollin  and  Moliere  described  an  osteoclast  which  could  break  the  femur 
within  two  fingers'  breadths  of  the  joint,  without  affecting  the  articula- 
tion in  any  degree.1 

Excision.- — The  operation  of  excision  of  the  joint  in  paralytic  knock- 
knee  must  be  mentioned.  Its  advantage  lies  in  the  fact  that  it  not  only 
corrects  the  deformity  but  stiffens  the  affected  joint,  which  is  a  great 
aid  to  those  patients  who  are  unable  to  wear  apparatus. 

Bow  Legs. 

Bow  legs  is  the  name  applied  to  the  opposite  deformity  to  knock- 
knee,  which  is  an  outward  angular  deformity  of  the  knee,  or  a  general 
outward  bowing  of  the  legs,  so  that  when  the  patient  stands  erect  with 
the  heels  together  the  knees  are  a  greater  or  less  distance  apart. 

The  condition  is  also  known  as  genu  varum,  genu  extrorsum,  out- 
knee,  bowed  legs  or  bandy  legs.  In  German  one  speaks  of  it  as  Sabel- 
bein,  Sichelbein,  O-bein,  and  in  French  as  Genou  en  dehors. 

It  is  single  or  double,  generally  the  latter,  and  may  exceptionally  ex- 
ist in  one  leg  when  knock-knee  is  present  in  the  other  (see  Fig.  511). 

Occurrence. — The  deformity  is  almost  always  the  result  of  an  outward 
yielding  of  the  long  bones  of  the  leg,  especially  of  the  tibia.  At  times, 
however,  it  is  clearly  due  to  an  obliquity  at  the  knee-joint,  where  the 
external  condyle  appears  the  larger  of  the  two. 

The  anatomical  changes  found  are  those  of  rickets.  The  bending  of 
the  bones  is  in  most  cases,  like  the  other  deformities  of  rickets,  a  simple 
yielding,  without  fracture  or  destruction  of  bone  tissue.2 

Causation. — Bow  legs  is  essentially  a  rhachitic  deformity  in  children, 
and  true  bow  legs  can  occur  only  in  a  child  whose  bones  are  soft  enough 
to  bend  easily.  It  occurs  in  the  first  three  or  four  years  of  life,  and 
ordinarily  in  connection  with  general  rickets ;    sometimes,  however,  other 


'Cent.  f.  Chir.,  1882,  ii.,  878;    Bull,  et  Mem.  de  la  Soc.  de  Chir.,  Paris,  1883, 
ix.,  885. 

2Kassowitz:  "Die  Symptome  der  Rachitis,"  Cent.  f.  Chir..  1887.  p.  179. 


566 


ORTHOPEDIC   SURGERY. 


rhachitic  manifestations  are  absent ;  but  the  yielding  of  the  bones  in  a 
child  of  this  age  must  of  itself  be  accounted  sufficient  evidence  of  rickets. 
Bow  legs  of  a  marked  type  are  seen  in  children  who  are  too  young 
ever  to  have  borne  their  weight  upon  their  legs.  To  account  for  them  by 
any  such  pressure  upon  the  bones  as  they  would  be  likely  to  get  from  the 
mother's  arm  in  a  constantly  changing  position  seems  iuadequate.  The 
explanation  is  that  the  tonic  action  of  the  muscles  of  the  legs  has  been 

sufficient  to  produce  this.  Muscular 
tonus  is  a  most  important  factor  in  pro- 
ducing this  deformity  of  the  legs.  Early 
walking,  so  much  talked  about  as  a  cause 
of  bow  legs,  is  not  to  be  accounted  a 
factor  of  any  importance  in  their  pro- 
duction unless  rickets  in  some  degree  is 
present. 

Why  the  bones  should  bend  outward 
as  they  do  is  a  question  which  is  by  no 
means  settled. 

The  child  with  rickets  stands  with 
thighs  flexed  and  the  lumbar  spine  arch- 
ed forward;  once  given  this  condition 
it  is  easy  to  see  how  bow  legs  arise.  As 
the  thighs  flex  the  knees  are  separated 
and  the  femurs  rotate  outward  on  their 
own  axes ;  as  a  result  of  this  the  liue  of 
gravity,  instead  of  falling  outside  of  the 
knee-joint,  as  we  have  seen  was  the  case 
in  the  normal  erect  position,  falls  inside 
of  it;  and  any  yielding  of  the  bones  of 
course  must  take  place  in  the  outward 
direction.  With  the  yielding  of  the  bones  the  line  of  the  legs  falls 
farther  and  farther  outside  of  the  line  of  gravity,  and  the  body  weight 
continually  acquires  better  leverage  to  bend  the  bones. 

Anterior  curvature  of  the  thigh  and  the  leg  bones  is  manifestly  the 
result  of  body  weight  coming  upon  a  flexed  limb  conjoined  to  the  action 
of  the  most  powerful  muscles  in  the  body  (the  flexor  muscles  of  the  thigh) 
pulling  in  the  same  direction. 

Subjective  symptoms  are  absent,  except  of  course  the  symptoms  of 
rickets.  But  the  deformity  is  plainly  evident,  and  even  in  the  milder 
cases  the  gait  is  modified  in  a  characteristic  way.  The  child  walks  with 
a  distinct  waddle  and  generally  with  the  feet  wide  apart  and  a  tendency 
to  invert  the  toes.  The  gait  in  bad  cases  bears  a  resemblance  to  the 
waddling  gait  of  double  congenital  dislocation  of  the  hips.  The  line  of 
the  leg  lies  so  much  outside  of  the  line  of  the  centre  of  gravity  that  in 


FIG.  522.— Shape  of   the  Bones  in  Bow 
Legs. 


KNOCK-KNEE    AND    BOW   LEGS. 


567 


bearing  weight  on  the  left  leg,  for  instance,  the  body  must  be  thrown 
decidedly  over  to  the  left  to  bring  it  over  its  line  of  support;  it  is  in  a 
measure  the  reverse  of  the  gait  in  knock-knee.  This  lurching  is  inevit- 
able with  each  step,  and,  other  things  being  equal,  is  in  a  degree  propor- 
tionate to  the  amount  of  curve  present. 

The  deformity  is  almost  always  more  conspicuous  in  the  standing 
position,  both  because  these  children  stand  with  the  legs  so  far  apart  and 


FIG.  523.— Child  Sitting  Turk  Fashion,  produc- 
ing, at  Junction  of  Lower  and  Mid-thirds  of  Legs, 
Anterior  and  Lateral  Bowing.  (Children's  Hos- 
pital Keport.) 


FIG.  534.— Child  with  Bow  Legs  in  Ordinary  Sit- 
ting Position,  Showing  Fitting  of  One  Leg  to  the 
Other.    (Children's  Hospital  Report.) 


because  the  knee-joints  generally  yield  somewhat  in  a  lateral  direction 
when  the  body  weight  is  superimposed. 

The  curve  is  most  often  a  gradual  and  uniform  bowing  of  the  femur 
and  tibia,  so  that  with  the  feet  together  the  outline  of  the  legs  forms  an 
oval  which,  in  severe  cases,  approaches  a  circle.  A  second  class  of  cases 
presents  a  bowing  chiefly  in  the  lower  third  of  the  tibia  which  is  more 
angular  in  character,  and  the  femurs  are  practically  normal ;  a  third  class 
presents,  either  alone  or  in  conjunction  with  the  other  deformities,  a  bow- 


568 


ORTHOPEDIC    SURGERY. 


ing  forward  of  the  tibia  and  sometimes  of  the  femur  also.  These  are  the 
three  common  types  of  the  deformity.  At  times  the  deformity  lies 
chiefly  in  the  knee-joint  and  the  bones  are  comparatively  straight. 

Rarely  one  sees  the  condition  of  knock-knee  and  bow  leg  existing  in 
the  same  leg. 

The  feet  in  cases  of  well-marked  bow  legs,  like  the  feet  of  all  rhachi- 
tic  children,  are  in  a  condition  of  flat-foot  in  nearly  all  cases.  They 
are  inverted  in  walking. 

The  bones  of  children  in  the 
active  stage  of  bow  legs  are  thought 
to  possess  an  abnormal  degree  of 
elasticity,    a    "  springiness "    it    is 


FIG.  535.— Standing  Position  of  Child  with  moder- 
ate Bow  Legs. 


Fig.  536.— Curve  involving  whole  Leg. 


commonly  called,  and  much  importance  is  attached  to  this  in  determining 
whether  or  not  the  stage  of  eburnation  has  begun.  One  obtains  this  by  grasp- 
ing the  upper  part  of  the  tibia  and  the  knee-joint  with  one  hand,  while 
with  the  other  the  lower  end  of  the  tibia  is  pressed  gently  outward  with 
a  quick  movement,  and  a  sensation  as  if  of  an  elastic  yielding  is  felt.  But 
it  is  doubtful  how  much  importance  should  be  attached  to  this,  and  to  a 
certain  degree  the  sensation  is  misleading  and  can  be  obtained  in  normal 


KNOCK-KNEE   AND   BOW   LEGS. 


569 


limbs  One  is  not  dealing  directly  with  the  bone,  but  with  a  bone  em- 
bedded in  soft  and  elastic-feeling  muscles,  and  also  it  is  impossible  to 
hold  the  knee  so  tightly  with  the  hand  as  to  exclude  the  elasticity  of  the 
ligaments  of  the  knee-joint  when  pulled  upon. 

3  Diagnosis.— The  condition  of  bow  legs  is  evident  on  inspection. 
Macewen's  definition  applied  to  this  deformity  would  be,  that  it  was  a 
condition  in  which  a  line  drawn  from  the  head  of  the  femur  to  the  mid- 
dle of  the  ankle-joint  would  fall 
inside  of  the  centre  of  the  knee- 
joint. 

It  is  often  difficult  to  deter- 
mine how  much  of  the  deformity 


Fig.  527.— Curve  involving  chiefly  Tibia. 


Fig.  538.— Anterior  and  Outward  Bowing 


lies  in  the  tibia  and  how  much  in  the  femur.  If  the  legs  are  crossed 
until  the  insides  of  the  knees  are  together  when  the  child  is  in  a  sitting 
position,  it  will  be  seen  whether  the  femurs  include  an  oval  space  be- 
tween them,  or  are  parallel  to  each  other. 

Prognosis.  —The  prognosis  in  bow  legs  is  favorable.  The  prospect  of 
spontaneous  outgrowth  of  the  deformity  is  better  than  in  knock-knee, 
and  in  young  children  rational  mechanical  treatment  offers  almost  sure 
relief.  The  prognosis  of  bow  legs,  when  untreated,  will  be  considered 
more  in  detail  in  speaking  of  the  treatment  by  expectancy.  Mechanical 
treatment  is  not  likely  to  benefit  cases  of  anterior  bowing  except  very 


570 


ORTHOPEDIC   SURGERY. 


slight  ones.  Operative  treatment  can  ameliorate  almost  any  condition  of 
deformity  and  often  entirely  rectify  it. 

Treatment. — The  treatment  of  bow  legs,  like  that  of  knock-knee,  is 
to  be  considered  under  three  heads :  (a)  expectant,  (b)  mechanical,  (c) 
operative. 

(«)  The  expectant  treatment  is  suited  to  a  large  percentage  of  cases  of 
the  deformity,  and  its  range  of  applicability  is  wider  than  in  knock- 


Fig.  530.— Spontaneous  cure  of  Bow  Legs. 


Fig.  539. — Anterior  Curve  of  Femur  and  Outward 
Bowing  of  Tibia. 


FIG.  531.  FIG.  532.        '  Fig.  533. 

Figs.  531,  532,  and  533.— Case  of  Bow  Legs.    Progress  in  three  years  under  expectant  treatment. 

knee.  The  mechanical  conditions  are  not  so  much  in  favor  of  the  in- 
crease of  the  deformity  as  in  knock-knee,  and,  if  the  osseous  softening 
stops  early  enough,  the  tendency  in  slight  cases  is  toward  rectification  in 


KNOCK-KNEE   AND   BOW   LEGS.  571 

the  course  of  growth.  In  general,  when  the  curve  is  uniform,  involving 
femur  and  tibia  alike,  the  chances  are  more  favorable  for  spontaneous 
cure  than  if  the  deformity  is  localized  in  the  tibia  and  more  angular. 

The  difference  between  a  gradual  bowing  of  the  legs  and  a  sharp 
angular  curvature  of  the  tibia  can  be  best  appreciated  by  taking  a  tracing 
of  the  legs  in  the  simple  way  already  described. 

The  figures  show  some  tracings  taken  at  random  from  out-patient 
cases  treated  by  expectancy,  attending  at  the  Children's  Hospital.  The 
parents  were  either  unwilling  to  begin  mechanical  treatment  or  were 
negligent  about  it;  but  at  the  end  of  three  or  four  years  the  children 
were  sent  for  as  a  matter  of  curiosity ;  and  two  representative  cases  are 
presented  in  the  figures.  Neither  of  these  had  any  treatment  whatever, 
and  there  is  no  reason  to  believe  that  these  are  exceptional  cases.  In 
these  cases  mechanical  treatment  was  advised  when  the  children  first 

came. 

The  number  of.  men  with  bow  legs  to  be  seen  in  the  streets  as  ob- 
served by  Whitman  was  four  hundred  out  of  two  thousand.  It  is  evident, 
therefore,  that  not  all  cases  of  bow  legs  recover  spontaneously.  For 
this  reason  it  is  far  safer  to  treat  cases  of  bow  legs  of  any  severity  by 
mechanical  measures,  always  bearing  in  mind  the  fact  that  there  is  a 
likelihood  of  their  complete  recovery  without  any  treatment  whatever. 

When  the  deformity  is  extreme  or  the  bones  are  eburnated,  it  is  not 
of  course  likely  that  the  child  will  outgrow  the  bow  legs.  It  is  only  in 
young  children  that  one  is  justified  in  expecting  it.  Expectant  treatment 
should  be  pursued  only  when  the  child  can  be  kept  under  observation 
and  tracings  of  the  legs  can  be  taken  sufficiently  often  to  see  whether  or 
not  the  deformity  is  increasing.  Any  increase  of  deformity  is  an  indica- 
tion for  mechanical  treatment. 

During  expectant  treatment  the  general  condition  should  be  most 
carefully  attended  to  and  rickets  treated  very  vigorously  from  the  first. 
The  child  should  be  encouraged  to  be  off  of  his  feet  as  much  as  possible, 
and  the  legs  should  be  rubbed  and  manipulated  each  night,  being  gently 
bent  toward  a  straight  direction. 

In  all  cases  tracings  should  be  taken  at  least  once  each  month,  to  de- 
termine if  the  deformity  remains  stationary  or  is  improving,  and  if  after 
two  or  three  months  no  improvement  is  evident,  mechanical  treatment 
should  be  begun. 

(b)  Mechanical  treatment  is  based  upon  the  principle  of  drawing  the 
knee  inward  to  a  rod  which  has  counter  points  for  sustaining  outward 
pressure  at  the  upper  part  of  the  thigh  and  at  the  ankle.  Here,  as  in 
knock-knee,  traction  from  a  rigid  rod  is  more  definite  and  more  satisfac- 
tory than  from  an  "elastic  one.  The  form  of  apparatus  used  is  of  little 
consequence  so  long  as  it  answers  the  indications  and  holds  the  knee 
extended.     It  is  no  longer  customary  to  treat  these  cases  by  recumbency. 


:»72 


ORTHOPEDIC    SURGERY 


A  simple  padded  inside  wooden  splint,  to  which  the  legs  are  bandaged, 
is  advocated  by  Noble  Smith. 

The  apparatus  shown  in  Figs.  r>.">4  and  r>.'!5  is  the  one  generally  in 
use  at  the  Children's  Hospital  in  ]>oston,  and  is  in  every  way  service- 
able. It  consists  of  a  steel  upright, 
which  is  attached  below  to  the  sole 
plate  of  the  shoe.  It  runs  up  nearly 
to  the  origin  of  the  adductor  muscles, 
but  it  must  fall  a  little  short  of  them  or 


Fi<;.  534. 


-Apparatus  for  Bow  Legs, 
pital  Report.) 


(Children's  Hos- 


Fi«.  535.— Same,  Applied. 


it  will  excoriate  the  skin  in  walking.  The  upright  is  then  bent  forward 
and  upward,  and  curved  to  fit  into  the  groin  and  come  up  as  far  as  the 
posterior  part  of  the  dorsum  of  the  ilium.  In  this  way  a  lever  is  pro- 
vided with  which  to  evert  the  feet  to  any  extent  by  altering  the  curve 
of  these  arms,  and  strapping  them  together  behind.  Pads  for  the  out- 
side of  the  legs  are  made  of  leather  and  buckled  by  two  or  three  straps 
to  the  upright,  opposite  the  greatest  convexity  of  the  curve.  In  severe 
cases  it  is  advisable  to  have  a  flat  steel  pad  plate  covered  with  leather, 
where  the  upper  part  of  the  upright  bears  against  the  thigh.  When  the 
curve  is  wholly  in  the  tibia  and  the  child  does  not  "  toe  in,"  it  is  sufficient 
to  carry  the  upright  just  above  the  knee,  and  to  end  it  there  in  a  pad. 

Anterior  tibial  curves  are  not  susceptible  of  improvement  or  cure  by 
mechanical  treatment  except  in  very  slight  cases  in  which  the  bones  are 
soft  and  the  curve  is  very  slight.  In  these  cases  it  is  useful  to  apply  to 
the  foot  a  steel  sole  plate  with  a  cup-shaped  rim  to  the* heel,  forming  its 
posterior  border.  To  this  two  uprights  are  attached  and  an  anterior  pad 
pulls  the  lower  part  of  the  tibia  backAvard,  pulling  from  these  uprights. 


KNOCK-KNEE    AND    KOW   LEGS. 


The  mechanical  treatment  of  bow  legs  should  be  advised  in  cases  in 
which  the  deformity  is  severe  or  sufficiently  obstinate  to  make  it  doubt- 
ful whether  spontaneous  outgrowth  of  the  deformity  will  occur,  because 
braces  do  no  harm,  and  do  not  retard  spontaneous  improvement.  After 
the  age  of  three  or  four  it  is  not  generally  worth  while  to  begin  mechani- 
cal treatment.  Children  who  are  too  old  for  mechanical  treatment  can 
either  be  operated  upon  at  once  or  allowed  to 
wait  as  long  as  one  wishes  for  operation,  for 
in  eburnated  and  hardened  bones  the  de- 
formity will  not  grow  any  worse. 

In  the  case  of  babies  the  expectant  plan 
of  treatment  is  the  one  to  be  followed  at  first. 

Mechanical  treatment  for  bow  legs  is  gen- 
erally useless  after  the  bones  have  become 
thoroughly  ossified. 

(c)   Operative  Treatment  of  Bow  Legs. 

Osteoclasis. — The  manual  fracture  of 
bones  is  a  procedure  which,  though  an  old 
one,  is  not  to  be  recommended.  Much 
force  is  required  even  in  the  case  of  the 
bones  of  young  children,  and  the  method  also 
lacks  precision  as  to  the  point  of  breaking. 
In  the  case  of  bones  still  soft,  if  it  is  desired 
to  operate  at  that  stage,  manual  fracture  has 
a  place  in  the  operative  treatment,  but  even 
then  manual  fracture  presents  no  advantage 
over  the  osteoclasts. 

Mechanical  fracture  is  made  feasible  by 
the  use  of  osteoclasts,  of  which  the  one  of 
Rizzoli  is  the  most  convenient.  The  appli- 
ance is  easily  understood  from  the  accom- 
panying illustration.  The  instrument  is  made  of  heavy  steel,  and  the 
rings  and  the  screw  pad  all  slide  on  the  bar  so  as  to  be  adjustable  to  any 
length  of  leg.  The  parts  of  the  apparatus  which  come  in  contact  with 
the  leg  are  padded  so  that  the  edges  shall  not  cut. 

Osteoclasis  is  a  simple  procedure.  The  instrument  is  applied  to  the 
bared  limb,  the  rings  being  adjusted  as  far  as  is  possible  from  the  point 
at  which  fracture  is  desired.  In  placing  the  rings  of  the  osteoclast  on 
the  limb  care  should  be  taken  not  to  put  them  too  near  to  the  joints  of 
the  ankle  or  knee,  as  the  epiphyses  might  be  separated  by  carelessness. 
The  screw  force  is  to  be  adjusted  so  as  to  press  at  the  point  of  election 
for  fracture,  which  is  at  the  point  of  the  greatest  convexity  of  the  curve. 
Pressure  is  increased  until  fracture  of  the  bones  takes  place.  The  fibula 
generally  breaks  first,  the  tibia  shortly  afterward  on  continuing  the  screw 


Fig.  536.— Splint  for  Bow  Legs. 
(Dane.) 


574 


ORTHOPEDIC   SURGERY. 


pressure.     The  fracture  of  the  boues  is  evidenced  by  a  loud  snap  which 
can  be  heard  anywhere  in  the  room. 

The  bone  will  usually  be  found  to  bend  before  fracture  occurs.     If 
the  instrument  is  well  padded  there  will  be  no  danger  of  injury  of  the 


Fig.  537.— Rizzoli's  Osteoclast. 


skin  from  the  temporary  pressure  necessary  for  fracture,  although  the 
amount  of  this  pressure  may  be  very  great.  The  skin  will  become 
blanched  .or  congested,  but  after  the  removal  of  the  osteoclast  the  color 
will  be  found  normal,  with  but  slight  evidence  of  pressure. 


WBF               '  [ 

'^^SBbh 

AjL 

jMBllyL  ; 

f:      "^ 

ySpBP    -NHWI 

l^" y-  ■ 

Fig.  538.— Method  of  applying  Osteoclast. 


The  fracture  will  be  found  to  have  taken  place  opposite  to  the  screw- 
pad  plate. 

After  the  bone  has  been  broken,  the  osteoclast  should  be  removed, 
the  fragments  placed  with  the  hand  in  the  desired  position,  without  any 
unnecessary  stirring  up  of  the  bones  at  the  seat  of  fracture,    sheet  wad- 


KNOCK-KNEE   AND   BOW   LEGS. 


575 


ding  placed  on  the  leg,  and  the  limb  fixed  in  a  plaster  bandage  and 
held  in  a  carefully  corrected  position.  The  bandage  should  reach  from 
the  toes  to  the  hip,  and  the  limb  should  be  held  in  the  corrected  position 
until  the  plaster  has  hardened  thoroughly.  When  there  is  a  rotation  of 
the  tibia  as  well  as  a  curvature,  care  should  be  taken  to  see  that  this  also 
is  remedied  and  that  the  limb  is  fixed  in  a  normal  position. 

Experience  has  shown  that  the  procedure  is  ordinarily  free  from  risk  j 
and  in  properly  selected  cases  the  danger  of  non-union  after  fracture  may 
be  disregarded.  The  fracture  is  a  transverse  one  and  there  is  no  danger 
of  splintering  the  bone.  A  number  of  experiments  upon  the  cadaver 
were  made  by  the  writers  with  reference  to  this  point,  and  it  was  found 


Fig.  539.— Bow  Legs,  curve  mostly  in  Tibia. 


Fig.  540.— Bow  Legs,  gradual  Curve  involving  the 
whole  Leg. 


that  although  splintering  will  take  place  in  dry  bone  if  subjected  to 
fracture  by  an  osteoclast,  yet  bone  undried,  as  found  in  the  dissecting- 
room,  will  break  transversely ;  the  fracture  takes  place  as  a  sharp  linear 
fracture  half-way  through  the  bone.  The  part  of  the  bone  nearest  the 
side  of  pressure  breaks  with  an  irregular  line  of  fracture,  as  if  torn. 

The  amount  of  force  required  for  the  fracture  of  an  adult  bone  is 
very  great,  so  much  so  as  to  make  osteotomy  in  most  instances  a  pref- 
erable procedure. 

Osteoclasis  near  the  joints  is  difficult,  but  in  the  shaft  of  the  tibia 
the  operation  is  a  most  excellent  one,  yielding  most  satisfactory  results 
with  but  little  discomfort  to  the  patient. 

In  the  large  number  of  cases  of  osteoclasis  which  have  come  in  the 
experience  of  the  writers  at  the  Boston  Children's  Hospital  they  know  of 
no  cases  in  any  way  unsatisfactory  in  the  results.  Cases  should  not  be 
operated  upon  unless  the  bones  are  fairly  strong— that  is,  not  if  the  rha- 
chitic  process  has  not  been  well  arrested— as  recurrence  of  the  deformity 
may  take  place.     This  has  occurred  a  few  times  in  the  experience  of  the 


570 


ORTHOPEDIC   SURGERY.      » 


writers  and  a  second  operation  lias  been  necessary,  but  such  cases  are 
very  rare,  and  have  served  only  to  emphasize  the  necessity  of  avoiding 
too  early  an  operation. 

Patients  have  been  operated  on  as  young  as  three  years,  but  as  a  rule 
the  operation  should  not  be  performed  before  the  age  of  four. 

The  limb  should  remain  in  a  fixed  bandage  for  four  or  five  weeks,  and 
no  appliance  is  needed  as  an  after-treatment. 

Anterior  Boic  Legs. — In  the  treatment  of  anterior  bowlegs  the  tibia 
may  be  broken  by  the  osteoclast  applied  in  the  usual  way,  and  after  the 
fracture  has  been  loosened  by  the  hands  the  leg  may  be  set  straight. 

Tenotomy  of  the  tendo  Achillis  aids  this 
attempt  and  is  generally  necessary.  Os- 
teotomy, however,  as  a  rule  is  more  satis- 
factory in  these  cases. 

Osteotomy  should  be  employed  in  place 
of  osteoclasis  in  cases  of  bow  legs  (1) 
when  the  curvature  is  so'  near  the  joint 
that  osteoclasis  is  not  practicable;  (2) 
when  the  bone  is  so  strong  that  osteoclasis 
is  not  feasible;  (3)  when  several  curves 
exist  in  the  same  leg,  or  when  the  curva- 
ture is  anterior;  (4)  in  cases  of  bow  leg 
in  which  the  distortion  is  largely  in  the 
lower  epiphysis  of  the  femur;  (p)  in  cases 
in  which  it  is  desired  to  locate  the  frac- 
ture very  accurately,  as  in  badly  united 
fractures  of  both  bones  of  the  leg  with 
displacement. 

Osteotomy  for  bow  legs  is  a  similar 
operation  to  that  for  knock-knee;  the  di- 
vision of  bone  is  made  wherever  it  ap- 
pears most  necessary,  and  no  formal 
operation  can  be  laid  down.  In  young 
children  the  fibula  need  not  be  cut  with 
the  osteotome  but  can  be  broken  manu- 
ally. Osteotomy  will  in  general  offer  the 
best  treatment  for  anterior  bow  legs.  The 
tibia  should  be  cut  nearly  through,  preferably  from  behind  at  the  level  of 
the  greatest  angularity,  and  the  limb  fractured,  and  tenotomy  of  the 
tendo  Achillis  will  generally  be  an  aid  to  the  rectification  of  the  foot.  It 
is  not  necessary  to  remove  a  wedge  of  bone  except  in  very  severe  cases, 
simple  linear  osteotomy  answering  every  purpose. 

The  removal  of  a  wedge  of  bone  shortens  the  leg  and  is  to  be  avoided 
if  possible.     It  is  necessary  only  in  very  sharp  curves.     It  is  often  better 


Fig.  541.— Anterior  Bow-legs. 


KNOCK-KNEE    AND   BOW   LEGS. 


577 


to  cut  the  posterior  surface  of  the  tibia  first  in  doing  osteotomy  for  an- 
terior bow  legs,  as  this  allows  the  line  of  fracture  to  gape  at  its  posterior 

aspect. 

A  practical  way  to  determine  the  amount  of  bone  to  be  removed  is 
the  following :  an  outline  of  the  leg  is  taken  by  means  of  a  tracing  drawn 
on  paper  and  then  cut  out.  If  a  wedge-shaped  section  of  this  profile  of 
the  leg  be  made  and  enough  removed  so  that  the  pattern  of  the  leg  be 
straight,  the  paper  wedge  will  indicate  the  amount  of  bone  which  needs 

removal. 

After  osteotomy  it  is  not  necessary  to  wire  the  fragments  of  bone  to- 


FiG.  542.— Slight  Grade  of 
Knock-knee  seen  after  Osteoto- 
my for  Bow  Legs. 


Fig.  543.— Composite  of  Ten 
Cases  of  Bow  Legs  before  Op- 
eration.    (Goldthwait.) 


Fig.  544.— Composite  Tracing 
of  all  Twenty-eight  Cases  (ex- 
cept the  Case  of  Relapse  above 
mentioned). 


gether;  if  they  are  placed  in  apposition  and  fixed,  union  can  be  ex- 
pected to  take  place. 

A  free  skin  incision  is  of  course  necessary  for  the  removal  of  a  wedge 
of  bone  from  the  tibia,  and  the  periosteum  should  be  incised  and  scraped 
away  from  the  proposed  seat  of  operation  with  very  great  care,  and  after 
the  removal  of  the  wedge  it  should  be  stitched  carefully  together.  In 
simple  linear  osteotomy  no  skin  incision  is  necessary. 

Ultimate  Results  of  Osteotomy  and  Osteoclasis.— J.  E.  Goldthwait 
traced  out  twenty-eight  cases  of  knock-knee  and  bow  legs  operated  on  in 
the  Children's  Hospital,  not  taking  into  account  any  case  operated  within 
a  year  and  a  half  of  the  beginning  of  his  investigation.  There  were 
eleven  cases  of  Macewen's  osteotomy  for  knock-knee  and  eleven  of  osteo- 
clasis for  bow  legs,  while  there  were  five  cases  of  anterior  bowing  of  the 
tibia  treated  by  osteotomy.  The  average  length  of  time  after  the  opera- 
37 


578  ORTHOPEDIC    SURGERY. 

tion  was  four  years,  and  of  these  cases  only  one  had  relapsed.  That 
was  a  colored  boy  four  and  one-half  years  old  who  presented  a  condition 
of  extreme  rickets.  He  had  both  knock-knee  and  bow  legs,  and  osteo- 
clasis and  osteotomy  were  done  and  the  knock-knee  had  recurred  some- 
what since  operation. 

The  figures  (543  and  544),  which  are  taken  from  composite  tracings 
of  each  group  of  cases,  show  the  condition  of  these  patients  before  and 
after  operation. 

The  figure  showing  tbe  combined  results  in  knock-knees  and  bow  legs 
might  be  liable  to  misinterpretation,  inasmuch  as  the  deformities  would 
counteract  each  other,  but  the  legs  of  all  these  children  were  perfectly 
straight. 

The  average  age  at  the  time  of  operation  was  four  years.  The  young- 
est child  was  two  years  old  and  the  eldest  ten. 

Non-Union  of  the  Bones. — Non-union  of  the  bones  is  very  rare  after 
either  osteotomy  or  osteoclasis.  Such  cases,  however,  occasionally  occur, 
as  in  a  case  reported  by  Marsh  to  the  Midland  Medical  Society,  in  which 
non-union  of  the  tibia  was  present.  In  this  case  this  seemed  to  be  at- 
tributable to  local  causes. 

Osteoclasis  is  preferable  when  it  is  possible,  as  being  theoretically  the 
safer  operation,  though  practically  statistics  show  such  excellent  results 
in  osteotomy  that  a  choice  of  methods  becomes  one  of  the  personal  pref- 
erence of  the  surgeon. 


CHAPTER  XIX, 
TORTICOLLIS. 

Definition.  — Etiology.  — Pathological  anatomy.  — Symptoms. —  Diagnosis.  —  Prog- 
nosis.—  Treatment. — Mechanical. — -Operative. — Congenital  elevation  of  the 
shoulder. 

Definition. 

The  name  torticollis  is  given  to  that  distortion  of  the  head  which 
causes  it  to  be  held  awry,  and  this  condition  is  either  constant  or  inter- 
mittent. 

The  other  names  by  which  this  affection  is  known  are  wry-neck,  caput 
obstipum,  collum  distortum,  cou  tortu,  Schiefhals. 

Etiology. 

Torticollis  may  be  congenital  or  acquired.  In  264  cases  Whitman1 
classed  32  as  congenital;  in  70  cases  analyzed  by  Redard2  18  were  con- 
sidered congenital. 

(1)  Congenital  Torticollis. — (a)  It  may  exist  in  connection  with  other 
deformities,  such  as  club-foot  and  similar  malformations.  In  these  cases 
it  seems  proper  to  attribute  its  existence  to  those  intra-uterine  conditions 
causing  other  deformities. 

(b)  Abnormal  pressure  of  the  uterus  seems  to  be  accountable  for 
another  class  of  cases  in  which  the  cranium  and  face  on  the  affected  side 
are  smaller  at  birth. 

(c)  Amniotic  adhesions  as  a  cause  are  spoken  of  by  Petersen. 

(d)  Inflammation  of  the  muscles  seems  to  be  proved  by  the  patho- 
logical findings  in  certain  cases  and  must  be  mentioned  as  an  occasional 
cause. 

(e)  Arrest  of  the  development  of  the  muscles  due  to  an  affection  of 
the  nerves  or  nerve  centres  must  be  spoken  of  as  a  cause  often  advanced 
to  account  for  torticollis.3 

(/)   Rupture  of  the  sterno-mastoid  muscle  occurring  at  birth  has  been 

'Trans.  Am.  Orth.  Assn.,  iv.,  p.  293. 
2"Le  Torticollis,"  etc.,  Paris,  1898  (full  bibliography). 

3 Osier:  N.  Y.  Med.  Journ.,  December  12th,  1891 ;  Golding  Bird:  Guy's  Hosp. 
Rep.,  1890;  Shaffer:  Trans.  Am.  Orth.  Assn.,  vol.  iv.,  p.  305. 


580  ORTHOPEDIC   SURGERY. 

much  discussed  '  as  a  cause  of  torticollis.  Although  for  many  reasons  its 
consideration  would  seem  to  come  rather  under  the  acquired  than  the 
congenital  class,  it  has  seemed  best  to  consider  it  here,  since  in  many 
instances  it  is  probably  the  result  of  congenitally  shortened  or  diseased 
muscles  and  because  it  exists  from  birth  when  present. 

In  the  majority  of  cases  of  congenital  torticollis  a  difficult  labor  has 
occurred  (Redard). 

Experiments  on  rabbits  by  Witzel,  in  which  haematoma  of  the  sterno- 
mastoid  muscle  was  caused  experimentally,  were  not  followed  by  torti- 
collis.2 Similar  experiments  by  Fabry,3  Mikulicz,4  and  Kader  were 
without  positive  results. 

There  is  no  question  that  rupture  of  the  muscle  occurs  at  times  dur- 
ing labor,6  and  haeruatoma  of  the  sterno-mastoid  muscle  is  not  an  ex- 
cessively rare  condition.  Pincus  and  Kader  report  series  of  cases  of 
haematoma.  Whitman  was  able  to  report  on  the  later  condition  of 
five  children  among  nineteen  cases  of  haematoma  of  this  muscle  seen  at 
the  Hospital  for  the  Ruptured  and  Crippled.  Among  these  there  was 
no  torticollis.  Quisling6  reached  a  similar  result  in  a  similar  series 
of  cases.  Redard  in  twelve  cases  observed  for  two  years  found  no  torti- 
collis resulting.  Brooks,7  Smith,"  and  Jacobi  have  reported  the  dis- 
appearance of  such  tumors  without  resulting  deformity.  It  has  been  de- 
monstrated experimentally  that  contusions  of  muscles  are  not  followed  by 
shortening  of  the  muscle.  A  case  was  seen  by  one  of  the  writers  shortly 
after  birth  with  a  haematoma  of  the  sterno-mastoid  muscle  but  no  marked 
torticollis,  and  two  years  later  appeared  with  a  typical  torticollis.9 

It  must  be  remembered  that  if  a  shortened  muscle  existed  during 
mtra-uterine  life  it  might  easily  be  ruptured  during  birth  10  and  form  a 
haematoma.  It  may,  then,  be  said  that  haematoma  of  the  sterno-mastoid 
muscle  in  most  instances  is  not  followed  by  torticollis. 

(</)  Imperfections  in  the  atlas  and  cervical  vertebrae  have  in  some 
reported  cases  been  the  cause  of  congenital  torticollis  (Uhde,  Rex). 


'Jeannel:  "Encyc.  Int.  de  Chir.,"  1886,  v.,  777;  Buscli :  Berl.  klin.  Wocii., 
1873,  xxxvii.  ;  Strouieyer :  "Handbch.  der  Chir.,"  ii.,  4;  Fischer:  Deutsch.  Chir., 
1880,  Lief.  43;  Volkmann  :  Cent.  f.  Chir.,  1885,  xiv.,  233. 

-Witzel:  Deutsch.  Zeit.  f.  Chir.,  1883,  xviii.,  534;  Petersen:  Zeitsch.  f.  Orth. 
Chir.,  i.,  L.  1,  113. 

3 Fabry:  Inaug.  Diss.,  Bonn,  1885. 

« Cent.  f.  Chir.,  1895,  No.  1. 

5Deutsckes  Arch.  f.  Chir.,  1882,  p.  181  ;  Cent.  fur.  Gyn.,  1886,  No.  9;  Bouchut: 
"Traite  Prat,  de  Mai.  des  Nouv.  Nees,"  Paris,  1750. 

*Arckiv  f.  Kinderheilkunde,  1891,  Bd.  xii.,  5  and  6. 

'N.  Y.  Med.  Rec,  Februarv  27th,  1886. 

8 Petersen  :  Cent.  f.  Gyn.,  1896,  No.  48. 

9R.  W;  Lovett:  Boston  Med.  and  Surg.  Journal,  1892. 

10Reneke:  Cent.  f.  Gyn.,  1886,  xxii. 


TORTICOLLIS.  581 

(2)  Acquired  Torticollis. — The  etiology  of  this  form  of  the  affection  is 
a  somewhat  difficult  matter  to  present  on  account  of  the  manifold  condi- 
tions which  may  cause  an  abnormal  position  of  fciie  head  either  tempo- 
rary or  permanent. 

There  are  several  well-recognized  types  which  may  be  considered 
first. 

(a)  Cicatricial  contraction  of  the  skin  or  deeper  tissues  following 
burns,  ulcerations,  and  similar  conditions  may  cause  torticollis. 

(b)  Traumatism  to  the  neck  and  head  is  at  times  followed  by  torti- 
collis, sometimes  apparently  due  to  direct  injury  to  the  muscles  of  one 
side  and  sometimes  to  a  synovitis  of  the  intervertebral  joints. 

(c)  Dislocation  of  the  upper  cervical  vertebrae  is  usually  accompanied 
by  torticollis. 

((/)  Inflammation  of  the  muscle.  Rheumatism  may  cause  inflamma- 
tion of  the  sterno-mastoid  or  other  neck  muscles  and  a  resulting  torti- 
collis. A  myositis  of  the  sterno-mastoid  muscle  may  occur  in  the  acute 
infectious  diseases,  such  as  typhus,  meningitis,  scarlet  fever,  diphtheria, 
etc.,  and  cause  torticollis.  A  similar  result  may  occur  from  a  chronic 
myositis,  possibly  ossifying  or  due  to  syphilis. 

(e)  A  form  of  torticollis,  wholly  reflex  in  character,  or  partly  reflex 
and  partly  mechanical  may  occur  in  inflammation  of  the  cervical  lymph 
nodes  or  with  deep  cervical  abscesses,  retropharyngeal  abscesses,  inflam- 
mations of  the  ear,  parotitis,  adenoid  vegetations  in  the  nasopharynx, 
tumors  of  the  neck,  and  cerebral  lesions.  Whitman  estimated  that  cer- 
vical adenitis  was  the  cause  of  fifty  per  cent  of  one  hundred  and  six  cases 
of  acquired  torticollis  analyzed  by  him.'1  Neuralgia  of  the  spinal  accessory 
or  cervico-brachial  nerves  may  be  accompanied  by  torticollis.2 

(/)  Ocular  torticollis  may  occur  when  a  difference  in  the  plane  of  vis- 
ion of  the  eyes  exists  or  when  a  difference  in  power  of  the  two  eyes  is 
present. 3 

(g)  Compensatory  torticollis  may  occur  as  secondary  to  lateral  curva- 
ture and  similar  deformities. 

(Ji)  Physiological  torticollis,  in  some  cases  severe  enough  to  require 
operation, i  has  been  described  in  which  the  voluntary  habit  of  holding 
the  head  to  one  side  has  become  a  permanent  deformity. 

(i)  It  may  result  from  certain  occupations  in  which  the  overuse  of  one 
sterno-mastoid  muscle  is  necessary,  as  in  the  case  of  a  factory  girl  who 
was  continually  compelled  by  her  work  to  turn  the  head  to  one  side,  or 
in  the  case  of  a  person  carrying  heavy  loads  continually  on  one  shoulder. 

'Whitman:  Orth.  Trans.,  vol.  iv.,  p.  293. 
2  Dollinger :  Pester  Med.  Chir.  Presse,  1889,  No.  48. 

3Bradford:  Trans.  Am.  Orth.  Assn.,  1889,  vol.  i.,  p.  46;  Lovett :  Trans.  Am. 
Orth.  Assn.,  1889,  vol.  i. 

4Mellet:  "Manuel  Prat.  d'Orth.,"  Paris,  1844. 


5.S2 


ORTHOPEDIC    SURGERY. 


(j)  Rickets  has  been  demonstrated  as  the  cause  of  some  cases 
(Phocas). 

(A)  Pott's  diseased  the  cervical  vertebra?  has  been  already  men- 
tioned as  a  frequent  cause  of  what  is  generally  classed  as  false  torticollis. 

(/)   Injury  to  the  nerve  centres  at  the  time  of  birth  may  apparently 


Fig.  545. 


cular  Torticollis, 
of  bead. 


Habitual  position       Fig.  546. 


-Ocular  Torticollis  ;    Back  View.      Ha- 
bitual position. 


cause  torticollis,  as  in  a  case  observed  by  the  writers  in  which  torticollis 
was  attributable  to  a  depressed  fracture  of  the  skull  caused  by  the  use 
of  forceps. 

(m)  Spastic  Torticollis. — In  this  class  are  included  those  cases  which 
arise  from  nerve  irritation.  This  may  be  central,  situated  along  the  course 
of  the  spinal  accessory  nerve,  or  may  be  the  local  manifestation  of  a  more 
general  nervous  irritation  as  in  spinal  irritation.  In  some  cases  of  the 
spasmodic  form,  the  affection  is  closely  allied  to  writers'  cramp,  spas- 
modic tic  of  the  face,  etc.,  and  in  one  case  observed  there  was  a  nodding 
motion  to  the  head. 

The  spasm  in  this  class  of  cases  can  be  either  tonic  or  clonic. 

Frequently  no  definite  cause  can  be  found  to  explain  the  occurrence 
of  the  affection,  but  it  is  evidently  the  result  of  general  malnutrition  or 
general  nervous  disturbance  having  this  as  a  local  manifestation.  Not 
infrequently  in  these  cases  there  will  be  found  a  definite  exciting  cause, 


TORTICOLLIS.  5  S3 

such  as  fright,  grief,  etc.  In  this  class  might  be  included  the ''torti- 
collis mental  "  of  Brissaud  '  and  Bompaire.* 

Many  of  the  above  causes  seem  each  to  be  but  one  out  of  many  factors. 
In  a  large  percentage  of  cases  there  will  be  found  to  be  a  neurotic  family 
or  personal  history,  also  the  general  condition  seems  to  have  a  very  con- 
siderable influence;  many  cases  occur  after  severe  overwork,  in  this  par- 
ticular bearing  a  close  analogy  to  professional  cramp  or  spasm. 

(n)  Paralytic  torticollis  may  rarely  occur  as  the  result  of  paralysis  of 
the  spinal  accessory  nerve  from  such  causes  as  rheumatism  or  trauma. 
It  may  also  result  from  anterior  poliomyelitis3  or  progressive  muscular 
atrophy.4 

Pathology. 

The  pathological  condition  existing  in  congenital  torticollis  has  been 
demonstrated  by  autopsy  and  by  pieces  of  muscle  removed  at  operation. 
In  some  instances  the  contracted  muscle  appears  normal,  but  more  often 
the  muscular  substance  is  replaced  by  fibrous  tissue.  This  may  occur  in 
small  patches5  or  the  whole  muscle  may  be  transformed  into  a  tendinous 
band.  In  the  majority  of  cases  of  fibrous  degeneration  of  the  muscle  it 
is  adherent  to  the  sheath,  and  in  some  instances  muscle  and  sheath  are 
fused  in  one  fibrous  band. 

The  sternal  part  of  the  muscle  ie  more  often  involved  than  the  clavic- 
ular. The  changes  described  are  to  be  classed  as  fibrous  myositis,  the 
reason  for  which  has  not  yet  been  formulated.  Other  muscles  besides  the 
sterno-mastoid  may  be  degenerated,  and  all  of  the  structures  on  that  side 
of  the  neck  are  of  ^ourse  shortened.  Changes  to  be  classed  as  perimyo- 
sitis  have  been  demonstrated  in  certain  cases." 

Shortening  of  the  muscle  on  the  affected  side  may  amount  to  several 
centimetres.  In  a  case  measured  by  Shaffer  when  the  patient  was  six 
years  old  and  again  Avhen  sixteen,  the  length  of  the  muscle  was  found  to 
be  the  same  at  both  times.7 

Secondary  changes  occur  in  long-continued  torticollis.  The  most 
marked  is  asymmetry  of  the  face;  a  deviation  of  the  line  of  the  nose 
from  a  right  angle  to  the  line  of  the  eyes,  is  noticed ;  furthermore,  the 
distances  from  the  outer  point  of  the  two  eyes  to  the  outer  corners  of  the 
mouth  are  not  the  same,  while  the  cheek  on  the  contracted  side  is  less 
prominent  and  the  features  on  the  affected  side  of  the  face  are  smaller 

1  Union  MMicale,  1804,  p.  161. 

2 "Torticollis  Mentale,"  These  de  Paris,  1894. 

sHoffa:  "Orth.  Chirurgie,"  1898,  p.  188. 

*Bejerine  and  Flandre,  quoted  by  Redard :  "Le  Torticollis,"  etc.,  1898,  p.  40. 

6Volkmann:  Cent.  f.  Chir.,  1885,  No.  14;  Vallert:  Ibid..  1890,  No.  38. 

6Archiv.  d.  Pediatrie,  1890,  No.  1. 

''Orth.  Trans.,  iv.,  p.  305. 


5  SI  ORTHOPEDIC   SURGERY. 

than  those  upon  the  other  side.  This  asymmetry  diminishes  if  the  de- 
formity is  corrected  early. 

Asymmetry  of  the  skull  may  also  be  found,  as  well  as  a  diminished 
size  of  the  cerebral  hemisphere1  on  the  affected  side.  The  carotid  artery 
of  the  affected  side  has  been  in  certain  cases  found  smaller.  * 

This  asymmetry  of  the  face  may  occur  in  acquired  torticollis,  and  it 
may  be  present  at  birth  in  congenital  cases.3  It  may,  on  the  other  hand, 
be  present  at  birth  without  the  existence  of  torticollis. 

Asymmetry  of  the  face  in  torticollis  has  been  attributed  to  many 
causes.  The  ones  most  deserving  of  mention  are  as  follows :  that  it  is 
due  to  muscular  tension;'1  to  a  difference  in  blood  supply  on  the  two 
sides ; 6  to  interference  with  the  function  of  one  side ;  to  respiratory  diffi- 
culty due  to  the  insufficiency  of  the  muscles  on  one  side. 6 

Lateral  curvature  of  the  spine  may  result  from  long-continued  torti- 
collis, and  a  difference  in  the  leugth  of  the  clavicles  has  been  noted. 

In  spasmodic  torticollis  gross  organic  lesions  are  not,  as  a  rule,  to  be 
found. 

Symptoms. 

Torticollis  is  either  acute  or  chronic.  In  the  acute  form  the  history 
is  that  of  an  acute  muscular  rheumatism  with  some  constitutional  dis- 
turbance and  sudden  onset  with  a  great  deal  of  pain  on  movement  of  the 
head,  and  the  head  is  held  to  one  side.  The  acute  stage,  however,  lasts 
but  a  short  time,  and  in  general  it  may  be  said  that  pain  in  wry-neck  is 
not  a  permanent  symptom.  The  chief  discomfort  from  wry -neck  is  the 
disfigurement  which  is  always  noticeable  and  never  to  be  concealed. 
There  may  be  pain  in  the  neighborhood  of  the  affected  muscles  and  their 
insertions.  Palpation  usually  discloses  considerable  tenderness.  The 
position  assumed  by  the  head  is  more  or  less  typical  and  is  described 
farther  on. 

The  chronic  form  may  develop  from  the  acute  form.  It  may  be,  as 
has  been  said,  a  congenital  distortion,  or  it  may  be  of  gradual  develop- 
ment from  any  of  the  causes  mentioned  above  or  from  no  known  cause. 

The  position  held  by  the  head  varies  necessarily  with  the  muscles 
affected.      When  the   sterno-cleido-mastoid   is  attacked,  the  ear  of  the 

'Greffie:  Montpellier  MeU,  November  16th,  1890;  Broca:  Bull.  MeU,  1894, 
No.  42,  p.  493. 

-  Witzel :  Loc.  cit. 

3  Osier:  N.  Y.  Med.  Journ. ,  December  12th,  1891;  Golding  Bird  :  Guy's  Hosp. 
Rep.,  xlvii.,  1890;  Krummacher :  Cent.  f.  Chir.,  1889,  No.  xii.  ;  Beely :  Zeitsch.  f. 
orth.  Chir.,  Bd.  ii.  ;  Meinhard  Schmidt:  Cent.  f.  Chir.,  July  26th,  1890. 

4 Ealkenburg :  Deutsch.  Zeit.  f.  Chir.  1885,  xix.,  338. 

8Bouvier :  "Loc.  Clin,  sur  les  Mai.,"  etc.,  Paris,  1858. 

6Strouieyer :  "Handbch.  der  Chir.,"  ii.,  p.  4,  1864. 


TORTICOLLIS.  585 

affected  side  is  brought  near  to  the  sternum  and  the  face  slightly  rotated 
to  the  opposite  side.  If  the  trapezius  or  posterior  muscles  are  also 
affected,  the  head  will  also  be  drawn  back,  the  chin  elevated  above  its 
normal  level,  and  the  features  on  the  side  of  the  spasm  drawn  below 
those  on  the  opposite  side.  In  severe  and  especially  in  persistent  cases 
the  jaw  is  rotated  so  that  the  teeth  cannot  be  approximated.  In  propor- 
tion to  the  extent  the  trapezius  is  involved  the  head  is  drawn  toward  the 
shoulder,  while  in  proportion  to  the  extent  in  which  the  spasm  involves 
the  sterno-mastoid  alone,  rotation  and  elevation  of  the  chin  predominate. 
In  addition  to  these  muscles  the  platysma,  the  scaleni,  splenii,  and  other 
deep  muscles  of  the  neck  are  sometimes  affected  and  modify  more  or  less 
the  position  of  the  head.  The  attitude  is  sometimes  so  peculiar  as  to 
render  it  difficult  to  determine  exactly  what  muscles  are  affected.  On 
palpation  certain  muscles  will  be  found  to  be  hard  to  the  touch  and  others 
flaccid;  no  pain  is  felt,  but  any  attempt  to  rectify  the  head  may  cause 
pain  if  persisted  in.  Rotation  of  the  head  is  free  up  to  a  certain  limit, 
varying  in  extent.  It  is  not  possible  to  move  the  head  in  a  direction 
against  the  spasm,  and  a  persistent  effort  may  cause  considerable  pain. 

But  in  old  torticollis  pain  is  absent  and  only  the  tough  contraction 
restricts  the  mobility.  In  the  opposite  direction,  motion  is  greatly  lim- 
ited, and  is  often  possible  only  by  slow  and  careful  manipulation.  As  a 
rule,  in  the  chronic  affection,  pain  and  tenderness  are  absent. 

A  deviation  of  the  spinal  column  and  a  lateral  curvature  with  rotation 
necessarily  follow  torticollis  and  may  materially  add  to  the  patient's  dis- 
comfort. In  order  to  retain  the  head  in  a  vertical  position,  the  patient, 
unable  to  twist  the  cervical  spinal  column,  will  twist  the  trunk,  leaving 
one  shoulder  leaning  to  the  side.  This  is  accompanied  by  rotation  of  the 
vertebrae  and  projection  of  the  ribs  backward  on  the  convexity  of  the 
lateral  curve,  precisely  as  is  seen  in  the  compensating  curves  of  any 
marked  lateral  curvature.  Although  the  head  is  twisted,  strabismus 
rarely  exists  except  in  cases  of  true  ocular  torticollis  already  mentioned. 
Although  the  movement  of  the  larynx  in  extreme  cases  is  apparently  lim- 
ited by  the  distortion,  speech  is  not  affected,  though  the  voice  in  singing 
may  become  modified  by  the  development  of  this  distortion. 

The  intermittent  form  of  torticollis  is  much  less  common.  In  the 
cases  observed  by  the  writers  it  was  due  to  the  disturbance  of  the  nerv- 
ous system  from  overwork,  and  to  anxiety.  At  times  the  head  could  be 
held  in  a  proper  position,  but  locomotion  or  any  excitement  or  the  appre- 
hension of  being  observed  would  produce  such  a  contraction  of  the  head 
that  it  would  be  twisted  violently  to  one  side  and  rotated  to  an  extreme 
limit.  A  slight  pressure  of  the  hand  steadying  the  head  would  ordinarily 
correct  it,  but  when  the  muscular  contraction  became  excited,  great  force 
was  required  to  hold  the  head  in  place.  In  a  recumbent  position,  the 
contraction  did  not  ordinarily  take  place.     It  usually  disappears  during 


586  ORTHOPEDIC    SURGERY. 

sleep.  The  spasm  is  sometimes  tonic  and  sometimes  clonic,  and  some- 
times pain  is  excited  by  the  muscular  contraction.  It  is  usually  confined 
to  the  muscles  of  one  side  (tic  giratoire).  In  one  instance  reported  by 
Studel,  the  muscular  cramp  alternated  between  the  muscles  of  the  left 
side  and  those  of  the  right,  constituting  a  veritable  chorea. 

Slight  twitchings  of  the  muscles  are  sometimes  observed  for  some 
time  previous  to  an  outbreak  of  the  spasmodic  condition. 

Diagnosis. 

There  is  no  difficulty  in  recognizing  the  deformity  called  wry-neck. 
The  head  is  twisted  to  one  side,  the  chin  being  to  the  right  or  left  of  the 
sterno-clavicular  notch,  while  the  face  is  turned  to  one  side  and  partly 
upward.  The  shoulders  are  held  obliquely  to  the  trunk,  twisted,  in 
order  to  bring  the  face  so  far  as  possible  in  a  vertical  line.  Certain  of 
the  muscles,  frequently  the  sterno-cleido-mastoid,  are  felt  hard  on  palpa- 
tion; some  rotation  of  the  head  is  possible,  but  perfect  free  rotation 
of  the  head  is  checked  by  the  contracted  muscles. 

A  diagnosis  of  the  cause  and  situation  of  wry-neck  is  more  difficult, 
as  well  as  an  attempt  to  distinguish  it  from  other  affections  which  give 
rise  to  this  malformation,  a  matter  which  is  of  great  importance.  Such 
are  disease  of  the  cervical  vertebra,  enlarged  cervical  glands,  cervical 
abscess,  and  stiff  neck  from  ordinary  cold. 

The  diagnosis  between  anterior  and  posterior  torticollis  (or  torticollis 
due  to  contraction  of  the  anterior  muscles,  chiefly  the  sterno-cleido- 
mastoid,  and  that  due  to  the  contraction  of  the  posterior  muscles,  the 
trapezius  and  splenius  capitis,  etc. )  is  to  be  based  on  palpation  chiefly. 

Palpation  also,  with  a  clinical  history  of  paralysis  and  the  evidence  of 
paralysis  elsewhere,  is  sufficient  usually  to  determine  the  diagnosis  of 
paralytic  torticollis. 

Torticollis  dependent  upon  enlarged  and  inflamed  glands  can  usually 
be  recognized  by  the  evidence  of  glandular  enlargement. 

There  is  ordinarily  little  difficulty  in  recognizing  the  common  acute 
wry-neck.  Its  course  is  acute,  the  deformity  appears  suddenly,  and  it 
is  usually  accompanied  by  pain.  Improvement  is  to  be  noticed  in  a  com- 
paratively short  time. 

For  the  diagnosis  of  real  torticollis  from  that  due  to  Pott's  disease  the 
reader  is  referred  to  the  chapter  on  Pott's  disease,  but  in  general  it  may 
be  said  that  in  the  latter  there  is  greater  rigidity,  and  this  involves  all 
the  muscles  of  the  neck,  and  particularly  the  posterior  groups.  The  pain 
elicited  by  attempts  to  twist  the  head  is  greater.  When  a  patient  with 
cervical  caries  attempts  to  lie  down  or  turn  over  the  head  is  instinctively 
steadied  with  the  hand,  while  in  true  torticollis  this  is  not  so  constant  a 
symptom. 


TORTICOLLIS.  587 

There  is  rarely  any  difficulty  in  distinguishing  anterior  torticollis  from 
wry-neck  due  to  caries  of  the  spine,  as  in  the  latter  one  sterno-mastoid 
muscle  is  not  prominently  contracted,  but  it  is  sometimes  impossible  to 
determine  without  several  examinations  and  a  continued  observation  of 
the  case  whether  posterior  torticollis  is  secondary  to  a  caries  oris  idio- 
pathic. It  may  be  said  that  in  all  cases  of  posterior  torticollis  Pott's 
disease  must  be  suspected,  and  the  symptoms  of  cervical  caries — referred 
pain,  projection  of  the  vertebra,  stiffness  of  the  back — must  be  carefully 
and  positively  excluded  before  a  diagnosis  of  posterior  torticollis  can  be 
formed. 

Prognosis. 

The  acute  idiopathic  wry-neck  due  to  muscular  inflammation  runs  a 
short  course  and  tends  naturally  to  recovery,  though  in  a  few  cases  it 
may  become  chronic.  Torticollis  due  to  abscess  of  the  cervical  glands 
terminates  with  the  complete  discharge  of  the  abscess  as  a  rule.  Inter- 
mittent spasmodic  torticollis  may  become  cured  spontaneously,  or  may, 
as  is  more  common,  remain  without  change  for  many  years.  Congenital 
forms  of  torticollis  and  the  common  acquired  form  (associated  with  mus- 
cular contraction  which  has  become  chronic  and  developed  fibrous  muscu- 
lar degeneration)  are  of  course  incurable  without  surgical  interference. 
Little  or  no  constitutional  disturbance  follows  this  affection,  which  is  more 
distressing  on  account  of  the  unsightliness  than  from  any  actual  discom- 
fort. 

The  deformity  is  one  which  is  eminently  curable  by  surgical  inter- 
vention. Complete  correction  and  permanent  cure  are  possible  in  all 
cases  except  in  the  intermittent  form,  which  is  dependent  upon  a  general 
depressed  state  of  the  nervous  system,  in  which  a  cure  cannot  always  be 
promised. 

Treatment. 

The  treatment  of  torticollis  depends  to  a  great  extent  on  the  variety. 
In  acute  torticollis  due  to  the  inflammation  of  the  muscles,  the  treatment 
is  largely  the  alleviation  of  the  symptoms.  This  is  best  done  by  the 
application  of  moist  heat  in  the  forms  of  cataplasms  and  poultices,  the 
inunction  of  oleate  of  atropine  or  morphine  to  relieve  the  pain,  or  the  sub- 
cutaneous injections  of  morphine.  Eestof  the  head  and  anti-febrile  con- 
stitutional treatment  are  of  course  advisable  Avhen  there  is  any  fever. 

Torticollis  due  to  cervical  Pott's  disease  is  treated  according  to  the 
principles  of  treatment  of  that  affection,  and  will  disappear  with  the 
improvement  of  the  bone  disease.  Torticollis  due  to  muscular  contrac- 
tion secondary  to  cervical  abscesses  or  enlarged  glands  is  corrected  by 
the  proper  treatment  of  cervical  abscess.  Torticollis  due  to  an  affection 
of  the  eye  is  to  be  corrected  by  proper  ocular  treatment. 


5S8 


ORTHOPEDIC   SURGERY 


The  treatment  of  wry-neck  due  to  permanent  muscular  contraction  is 
either  operative,  or  purely  mechanical,  or  mechanical  and  operative. 

Mechanical  Treatment. — Mechanical  treatment  without  the  aid  of 
operation  is  usually  unsuccessful,  except  in  the  lightest  cases. 

-Massage  and  passive  manipulation  are  of 
value  in  mild  cases  in  connection  with  me- 
chanical treatment. 

The  simplest  of  all  forms  of  appliance  is 
that  invented  by  Buckminster  Brown,  of  Bos- 
ton. A  wire  collar  passes  around  the  neck 
and  is  furnished  with  a  plate  under  the  chin, 
arranged  so  as  to  press  on  the  deflected  side 
of  the  chin.  Pressure  is  also  arranged  to  be 
applied  to  the  inclined  side  of  the  head  behind 
the  ear.  The  wire  collar  is  attached  to  a  ring 
which  rests  upon  the  shoulder,  and  in  the  back 
this  is  furnished  with  an  arm  which  passes 
down  the  back.  Straps  are  fastened  to  this, 
one  passes  around  the  trunk,  and  another 
around  the  shoulder  on  the  side  of  the  deflect- 
ed chin ;  by  tightening  this  latter  strap  it  will 
be  found  that  pressure  is  exerted  on  the  chin 
in  the  proper  direction. 

Mechanical  treatment  is  of  value  chiefly 
in  retaining  the  correction  obtained  by  opera- 
tive measures. 

Operative  Treatment. — The  operative  pro- 
cedures are  tenotomy  and  open  incision. 

Tenotomy  is  applicable  to  contraction  of  the  sterno-cleido-mastoid 
muscle.  The  place  of  election  for  division  of  the  sterno-mastoid  is  in  its 
lower  part.  In  its  upper  part  it  is  more  or  less  surrounded  with  nerve 
filaments.  A  strong  tenotome  is  selected,  the  skin  is  pulled  down  and 
the  tenotome  is  inserted  through  the  skin  and  over  the  clavicle.  The 
skin  is  then  allowed  to  slip  up  and  the  tenotome,  which  has  been  in- 
serted in  the  skin,  moves  with  it  and  should  lie  half  an  inch  to  an  inch 
above  the  clavicle.  Care  should  have  been  taken  to  avoid  the  external 
jugular  vein  which  is  readily  seen  or  made  apparent  by  pressure  and  dis- 
tention of  the  vein.  The  blade  of  the  tenotome  is  then  passed  under- 
neath the  contracting  muscle  and  its  sheath,  its  cutting  edge  is  then 
turned  toward  the  skin  and  by  a  careful  sawing  motion  the  tendon  is  felt 
to  give  way;  it  being  essential  that  all  of  the  contracting  tissue  be  di- 
vided and  that  the  muscle  be  not  simply  transfixed.  After  this  the  head 
should  be  fixed  in  the  corrected  position. 

The  head  should  be  immediately  rectified  and  retained  in  a  corrected 


Fig.  547.— Buckminster   Brown's 
Wire  Collar  for  Holding  Head. 


TORTICOLLIS. 


589 


position,  either  by  means  of  a  plaster-of -Paris  bandage  enclosing  thi 
and  trunk,  or  by  placing  the  patient  in  bed  secured  to  the  bed  frame 
described  in  the  treatment  of  caries  of  the  spine,  and  applying  straps, 
sticking-plaster,  and  weights  in  the  manner  shown  in  the  accompanying 


Fig.  548.  Fig.  549. 

FIGS.  548  and  549.— Retention  Appliance  for  Torticollis.    (Children's  Hospital  Report.) 

illustration.  This  can  be  employed  for  a  week  or  ten  days  and  a  light 
retention  appliance  be  used,  that  of  Buckminster  Brown  being  found 
simple  and  convenient. 

Open  Incision.— It  will  be  found  practically  impossible  in  most  cases 
to  divide  entirely  with  the  tenotome  all  the  deeper  contracted  fibres,  and 
much  will  have  to  be  left  to  mechanical  stretching.  For  this  reason  an 
open  incision  is  more  thorough  and  preferable  to  tenotomy  as  offering 
the  best  means  of  correction.  The  writers  have  entirely  abandoned  sub- 
cutaneous tenotomy  in  the  treatment  of  wry-neck  in  favor  of  open  inci- 
sion. 

An  incision  parallel  to  the  clavicle  and  an  inch  above  it  should  be 
made  reaching  across  the  contracting  muscle,  a  director  should  be  passed 


590 


ORTHOPEDIC    SURGERY. 


under  the  muscles  and  fascia,  and  the  whole  divided  with  care.  After 
this  is  done,  the  skin  should  be  sewn  up  and  the  head  fixed.  The  head 
should  be  kept  in  an  over-corrected  position  until  union  of  the  divided 
structures  has  taken  place.  In  ten  days  or  a  fortnight  the  Buckininster 
Brown  head  support  can  be  applied. 

This  latter  should  be  worn  for  from  three  to  six  months,  when  per- 
manent cure  should  be  established.  Without  the  use  of  apparatus  after 
operation  relapse  is  likely  to  occur. 

Both  in  tenotomy  and  in  open  incision  there  is  danger  of  wounding  the 
internal  jugular  vein;  deaths  from  this  cause  have  been  reported  after 
tenotomy.  The  writers  would  record  one  case  in  their  experience  in  which 
the  internal  jugular  was  wounded  in  an  open  incision.     It  was  tied  and  no 


Fig.  550.— Side  Traction  for  Twisting  the  Head  in  Torticollis  after  Operation.    (Children's  Hospital 

Report.) 


untoward  results  followed,  the  patient  making  a  perfect  recovery.  The 
vein  lies  under  the  deep  fascia,  and  can  be  avoided  in  open  incision  if 
the  neck  be  not  stretched  and  care  be  taken  not  to  open  the  deep  cervical 
fascia. 

The  results  of  the  correction  of  torticollis  by  open  division  are  ex- 
tremely satisfactory.  The  asymmetry  of  the  face  becomes  more  notice- 
able after  correction  than  it  was  in  the  deformed  position,  but  disappears 
gradually  if  the  corrected  position  is  retained. 

Beside  the  deformity  largely  associated  with  contraction  of  the  sterno- 
mastoid  muscle — anterior  torticollis — another  form  is  seen,  as  has  been 
already  mentioned,  viz.,  posterior  torticollis.  This  variety  constitutes  a 
class  of  obstinate  cases.  The  only  efficacious  treatment  is  that  of  forcible 
correction  without  tenotomy,  for  the  reason  that,  as  a  rule,  the  muscles 
are  too  deep  or  extensive  to  be  tenotomized.  The  writers  have  divided 
the  outer  bands  of  the  anterior  scalenus  and  trapezius  by  open  incision 
and  can  report  the  feasibility  of  the  procedure.     In  correcting  this  de- 


TORTICOLLIS. 


591 


formity  the  patient  should  be  thoroughly  anaesthetized,  and  an  assistant 
should  hold  the  shoulders  firmly,  while  the  patient  should  be  so  placed 
that  the  head  projects  beyond  the  end  of  the  operating-table.  The  head 
should  be  held  by  the  hands  of  the  surgeon  and  rotated  in  all  directions, 
considerable  force  being  used.  The  danger  of  fracturing  the  spine  is  in 
such  cases  of  course  so  slight  as  to  be  disregarded,  and  the  deformity  can 
be  over-corrected.  After  the  operation  the  head  should  be  fixed  in 
some  retaining  appliance. 

The  use  of  correcting  appliances  will  be.  required  several  months  after 
operation  to  enable  the  soft  parts  to  adapt  themselves  to  the  normal 


Fig.  551.— Result  of  Open  Incision  and  Correc- 
tion in  a  Girl  of  Eight,  One  Month  after  Opera- 
tion. 


FIG.  552.— Result  of  Open  Incision  One  Year 
after  Operation  in  a  Girl  of  Sixteen.  Shows  also 
the  unequal  development  of  the  face. 


position.  When  the  patient  is  under  an  anaesthetic,  complete  correction 
or  over-correction  during  the  operation  is  a  method  which  saves  the 
patient  suffering  and  gives  the  best  results.  The  selection  of  the  form  of 
retention  appliance  will  depend  upon  circumstances;  fixed  plaster-of- 
Paris  bandages,  removable  stiffened  leather  collars,  moulded  upon  a  cast, 
or  the  light  steel  appliance  already  described  will  be  found  efficacious, 
the  last  being  the  least  unsightly  and  uncomfortable  to  the  patient. 

The  treatment  of  torticollis  may  be  summarized  as  follows :  Anterior 
variety :  division  by  open  incision  of  such  muscular  bands  or  fibres  as 
are  within  the  reach  of  the  knife.  Posterior  variety  :  manual  correction 
and   over-correction   of   the   deformity    under    an   anaesthetic;    fixation 


592 


ORTHOPEDIC   SURGERY. 


of  the  head  in  an  over-corrected  position  and  the  subsequent  wearing  of 
retention  appliances.  It  may  be  added  that  the  result  of  thorough  treat- 
ment is  most  satisfactory. 

Spastic  Torticollis. — The  treatment  of  spastic  torticollis  is  mechanical 
and  constitutional.  These  cases  are  often  largely  due  to  a  depressed  ner- 
vous condition — a  condition  requiring  for  a  cure  an  improvement  in  the 
patient's  nervous  condition. 

Fixation,  however,  is  sometimes  of  benefit;  one  care  is  reported1  by 
the  use  of  a  plaster  helmet.  Hall 2  reported  two  cures  from  the  wearing 
of  a  spring  clamp  on  the  back  of  the  neck.     The  apparatus  consisted  of  a 


Fig.  553. 


-Posterior   Torticollis    before    Forciblb 
Straightening. 


Fig.  554.— After  Operation. 


light  circular  steel  spring  like  the  ordinary  trousers  clamp  for  the  use  of 
bicyclists.  This  reached  as  far  forward  as  the  anterior  border  of  the 
sterno-mastoid  muscles  and  had  a  vertical  attachment  of  steel,  running 
down  the  back  for  six  inches  in  the  median  line,  which  went  under  the 
collar.  The  horizontal  piece  was  most  efficient  when  at  the  level  of  the 
jaw.  Lund3  recorded  a  cure  from  the  use  of  an  apparatus  which  held 
the  head  fixed  in  a  somewhat  extended  position.  This  consisted  of  an 
upright  running  the  length  of  the  spine,  terminating  above  in  two  lateral 
pads  steadying  and  fixing  the  occiput  by  means  of  a  strap  passing  around 
the  forehead.      Such  treatment  is,  however,  generally  unsatisfactory. 


1  Quoted  by  Hall. 

-H.  J.  Hall:  Orth.  Trans.,  vol.  xi.,  p.  233. 

3  Boston  Med.  and  Surg.  Journ.,  March  9th,  1899,  p.  23(5. 


TORTICOLLIS.  593 

Constitutional  treatment  in  the  way  of  change  of  scenery  and  air,  and 
rest  from  occupation  are  of  great  help,  in  some  instances  of  clonic  torti- 
collis there  is  a  spontaneous  cure;  but  with  these  exceptions  torticollis  is 
an  affection  which  becomes  persistent,  and  unless  corrected  becomes  a 
permanent  deformity. 

Massage  and  galvanism  to  the  affected  muscles  are  apparently  of  bene- 
fit in  a  certain  number  of  cases.  These  are  almost  without  exception  of 
the  clonic  form  and  in  patients  whose  system  has  been  overtaxed,  and 
attention  to  the  health  is  of  fully  as  great  importance  Systemal  ie  mus- 
cular exercises  and  development  of  muscular  control  by  muscle  training 
have  been  beneficial. 

When  conservative  measures  have  been  unsuccessful  recourse  can  be 
had  to  operative  methods.  These  have  been  successful  in  a  number  of 
instances  in  the  hands  of  Kocher,  Keen,  and  Richardson. 

Nerve-stretching  of  the  branch  of  the  spinal  accessory  supplying  the 
sterno-mastoid  as  well  as  division  of  the  nerve  has  been  of  temporary 
benefit,  but  is  usually  followed  by  a  relapse.  And  as  other  muscles  be- 
sides the  sterno-mastoid  are  involved  in  the  causation  of  this  deformity, 
Keen  has  recommended  and  practised  a  division  of  the  roots  of  the  pos- 
terior cervical  nerves  in  addition  to  the  division  of  the  branch  of  the 
spinal  accessory.  Relapse,  however,  may  follow  these  measures  in  cer- 
tain instances,  although  in  some  cases  an  ultimate  cure  results. 

The  operation  requires  careful  dissection  from  an  incision  parallel 
and  to  the  outside  of  the  sterno-mastoid  in  front,  and  behind  parallel 
with,  but  a  few  inches  to  the  outside  of,  the  cervical  spine.  It  is  neces- 
sary in  the  latter  incision  to  pass  through  the  trapezius.  These  opera- 
tive measures  are  to  be  performed  usually  in  two  sittings,  and  are  to  be 
followed  by  fixation  and  later  by  measures  to  improve  the  muscular  tone, 
by  massage,  and  by  applying  electricity  to  the  weakened  muscles.  In 
some  instances  myotomy  of  the  spastic  muscles  has  been  reported  to  be 
followed  by  success.  In  some  instances  in  which  failure  has  apparently 
followed  operative  interference,  a  permanent  subsequent  cure  resulted 
after  several  months'  treatment  by  massage — previously  unsuccessful,  as 
if  the  division  of  the  nerve,  fascia,  or  muscle  was  essential  to  the  cure. 

Congenital  Elevation  of  the  Scapula. 

This  condition,  known  also  as  u  Sprengel's  deformity"  and  "  ange- 
borener  Hochstand  der  Scapula,"  is  a  somewhat  unusual  congenital  affec- 
tion in  which  one  scapula  is  raised  in  relation  to  the  thorax  and  to  the 
clavicle  of  the  same  side  as  well  as  to  the  opposite  scapula.  The  scap- 
ula is  usually  not  only  raised  but  so  rotated  that  its  lower  angle  ap- 
proaches the  spine.  This  rotation  may  be  absent.  There  is  usually 
some  limitation  of  motion   of  the  scapula  and  a  resulting  inability  to 


594 


ORTHOPEDIC   SURGERY, 


raise  the  arm.  to  the  normal  extent;  in  most  of  the  cases  this  is  associ- 
ated with  scoliosis  of  a  varying  degree.  The  only  theory  to  account  for 
the  origin  of  the  affection  is  that  of  Sprengel,  that  the  arm  has  lain 
behind  the  back  in  utero,  a  position  recurring  in  some  of  these  cases 

after  birth  and  a  position 
which  would  certainly  tend 
to  produce  the  position  of 
the  scapula  actually  found. 
There  is  a  question  as 
to  the  existence  of  the  ex- 
ostosis described  by  some 
authors  as  being  present. 
The  scapula  itself  and  its 
muscles  are  approximately 
normal  in  most  cases.  Kol- 
liker  describes  a  type  of 
affection  in  which  the  de- 
formity is  actually  depend- 
ent upon  bony  change, 
which  is  a  bending  for- 
ward of  the  body  and  neck 
of  the  scapula  with  tilting 
and  raising  as  well.  This 
type  he  believes  to  be 
rhachitic. 

The  affection  in  general 
is  serious  only  as  an  asym- 
metrical deformity  and  the 
limitation  of  the  use  of  the 
arm  is  not  great. 
Various  operations1  for  the  relief  of  the  affection  have  been  performed. 
Pitsch  and  Kolliker  removed  the  upper  inner  angle  of  the  scapula  with 
marked  improvement.  Bolten  and  Eulenburg  have  described  cases  in 
which  division  of  the  trapezius,  etc.,  was  of  benefit.  The  cutting  of  this 
contracted  muscle  was  combined  with  massage,  etc.  In  a  case  operated 
on  by  one  of  the  writers,  extensive  division  of  the  contracted  muscle  was 
followed  by  slight  improvement,  but  much  difficulty  was  experienced  in 
holding  the  scapula  in  the  corrected  position. 

•Sprengel:  Arch.  f.  klin.  Chir.,  xlii.,  545;  Sainton:  Rev.  d'Orthopedie,  1898, 
ix.,  467  ;  Bolten:  Munch,  med.  Woch.,  1892,  xxxix.,  671  ;  Pitsch:  Zeitschr.  f.  orth. 
Chir.,  1898,  vi.,  p.  52;  Kolliker:  Centralbl.  f.  Chir.,  xx.,  643;  Arch.  f.  klin.  Chir., 
1898,  lvii.,  778;  Eulenburg:  37te  Versamml.  Deutscher  Naturf.  u.  Aerzte  (ref. 
Pitsch). 


, 


if 


Pig.  555.— Congenital  Elevation  of  the  Scapula. 


CHAPTER  XX. 

UNILATERAL   ATROPHY   AND    HYPERTROPHV. 

Etiology  and  Occurrence. 

Cases  of  unilateral  difference  in  the  growth  of  the  body  have  recently 
attracted  considerable  attention  chiefly  because  of  their  obscure  etiology. 

Hunt,1  of  Philadelphia,  in  1879,  made  observations  which  led  him  to 
state  that  bilateral  symmetry  as  to  the  length  of  the  lower  limbs  was 
exceptional.  Since  then  several  observers  have  corroborated  the  views 
of  Hunt.  Dr.  Cox2  measured  the  lower  limbs  in  fifty-four  healthy  per- 
sons, and  in  only  six  were  the  limbs  of  the  same  length.  There  was  no 
uniformity  with  regard  to  which  side  was  the  longer.  The  variation  in 
length  was  from  one-eighth  to  seven-eighths  of  an  inch.  Wight 3  gives 
the  measurements  of  sixty  persons,  and  concludes  "  that  the  greater  num- 
ber of  limbs,  comparing  the  limbs  of  the  same  person,  show  a  difference 
in  length.  About  one  person  in  every  five  has  limbs  of  the  same  length." 
The  difference  is  usually  from  one-eighth  of  an  inch  to  an  inch.  In  one 
case  the  difference  was  as  great  as  one  and  three-eighths  inches. 

Callender4  measured  forty  individuals,  and  found  the  limbs  of  equal 
length  in  all  but  two,  in  whom  the  variation  was  slight.  He  used  a 
simple  tape — all  the  persons  measured  happened  to  be  Englishmen. 
Roberts5  and  Dwight 6  have  attempted  to  settle  the  question  by  observa- 
tion on  the  bones  of  skeletons.  Roberts  found  asymmetry  the  rule  in 
femora  and  tibiae  in  eight  skeletons.  Dwight  reported  measurements  in 
eleven  skeletons;  in  five  the  femora  were  equal;  in  one  case  the  differ- 
ence was  three-quarters  of  an  inch.  Tibiae  were  equal  in  only  two  cases. 
In  some  cases  the  longer  femora  and  tibiae  were  on  the  same  side,  and 
in  some  cases  on  different  sides. 

Dr.  J.  Garson, 7  of  London,  published  the  results  of  the  measurements 
of  seventy  skeletons.  The  lower  limbs  were  equal,  he  says,  in  only  ten 
per  cent. 

1  Am.  Journal  Med.  Sciences,  January,  1879. 

2  Am.  Journal  Med.  Sciences,  April,  1875. 

3  Archives  Clin.  Surg.,  vol.  i.,  No.  8,  February,  1877. 

4 St.  Bartholomew's  Hospital  Reports,  vol.  xiv.,  1878,  p.  187. 

5  Philadelphia  Med.  Times,  August  3d,  1878. 

6  Mass.  Med.  Soc.  Communications,  1878,  p.  175. 

'Journal  of  Anat.  and  Phys.,  vol.  xiii.,  p.  502,  1879;  Nature,  January  26th, 
1884. 


596  ORTHOPEDIC    SURGERY. 

Morton1  has  made  many  measurements  and.  found  that  among  513 
boys  292  presented  inequality  in  the  length  of  the  lower  limbs  varying 
from  one-eighth  of  an  inch  to  one  inch  and  five-eighths.  In  241  there 
was  no  appreciable  difference  in  length.  In  none  of  these  cases  had 
there  been  previous  fracture  or  any  bone  or  joint  disease  which  might 
have  accounted  for  the  defect.  Three  of  the  boys,  including  those  that 
exhibited  the  greatest  shortening,  were  aware  of  the  fact  that  one  limb 
was  deficient  in  length.  Burrell "  reported  three  cases  of  marked  uni- 
lateral atrophy  only  noticed  when  the  children  began  to  walk,  when  it 
became  manifest  by  a  limp. 

Broca:i  relates  the  case  of  a  boy  of  eleven  who  appeared  "  as  if  the 
two  halves  of  the  body  were  different-sized  persons  joined  together." 

Paget '  found  that  there  is  often  a  difference  of  volume  as  marked  as 
is  the  difference  in  length,  and  it  is  often  difficult  to  say  which  of  the 
two  unequal  limbs  is  the  better  or  the  more  appropriate  to  the  other 
parts  of  the  body.  In  Hartwig's  studies  of  the  upper  extremity  the 
bones  of  the  right  arm  were  found  to  be  the  longest,  corresponding 
with  Hyrtl's  results.  Poncet  °  reported  a  case  of  alternate  inequality, 
the  right  arm  and  the  left  leg  being  better  developed. 

The  conclusions  reached  by  all  have  been  nearly  identical,  namely, 
that  throughout  the  long  bones  of  both  extremities  there  exists  often  a 
certain  amount  of  asymmetry  in  regard  to  length. 

The  very  important  theoretical  and  practical  bearing  of  this  is  easily 
seen.  The  relation  that  short  limbs  may  bear  to  cases  of  lateral  curva- 
ture6 has  been  discussed. 

The  progressive  facial  hemiatrophy  is  of  interest  from  an  etiological 
standpoint. 

The  etiology  of  these  different  forms  of  atrophy  or  hypertrophy  is 
obscure.  In  the  cases  of  injury  to  the  joints  Nicoladoni  suggested  a  pre- 
mature synostosis  of  the  epiphyseal  cartilages.  The  facial  hemiatrophy 
is  thought  to  be  a  trophic  neurosis  of  certain  nerve  ganglia  or  nerves — or 
a  simple  vascular  disturbance  of  the  part  has  been  suggested  as  a  possible 
cause. 

It  is  probable  that  certain  of  these  cases  are  the  result  of  a  slight 
former  hemiplegia,  which  has  manifested  itself  chiefly  in  retarding  the 
growth  of  the  affected  side  without  any  distinct  loss  of  motor  power. 
This  seemed  probable  in  a  case  recently  seen  by  the  writers,  in  which  the 
right  side  of  the  body  was  distinctly  behind  the  left  side  in  growth,  but 

1  "Asymmetry  of  the  Lower  Limbs,"  etc.,  Phila.  Med.  Times,  July  10th,  1886. 

2  Boston  Med.  and  Surg.  Journal,  vol.  cvi..  p.  462. 
3Canstatt's  Jahresbericht,  1859,  vol.  iv..  p.  6. 

4  Am.  Journal  Med.  Sciences,  January,  1886. 
6  Lyon  Medical,  January  29th,  1888. 
6 Revue  de  Chirurgie,  April  10th,  1888. 


UNILATERAL  ATROPHY   AND    HYPERTROPHY.  597 

the  left  side  of  the  head  was  smaller  than  the  right  side — a  relation  which 
suggested  most  strongly  the  existence  of  some  lesion  of  the  trophic  cen- 
tres in  the  left  cerebral  hemisphere. 

Symptoms  and  Treatment.- — Long-continued  slight  and  oftentimes 
severe  backaches,  with  lumbar  and  pelvic  pain,  involving  the  distribution 
of  the  sciatic  nerve,  are  often  due  to  asymmetry  of  the  lower  limbs. 
Such  symptoms  are  at  times  at  once  relieved  upon  correcting  the  asym- 
metry. A.  person  in  previous  good  health  may  from  some  depressing 
physical  condition  begin  to  have  the  above  symptoms  of  pain  localized 
as  stated,  and  upon  examination  unequal  limbs  will  be  found  in  very 
many  cases. 

Morton  said  that  United  States  pension  examining-surgeons  stated 
that  many  applications  for  pension  have  been  made  for  disabilities  de- 
scribed as  lumbago,  supposed  to  have  been  caused  by  exposure  or  by 
injuries  contracted  during  the  war  for  the  Union.  In  nearly  all  such 
cases  an  examination  revealed  a  previously  unrecognized  asymmetry,  and 
the  symptoms  were  probably  induced  by  this  defect  in  development. 

Symptoms  of  inequality  of  the  lower  limbs  may  simulate  coxalgia. 
In  such  cases  the  legs  should  of  course  be  measured.  Children  complain- 
ing of  backache,  or  so-called  growing  pains,  should  be  carefully  examined 
for  any  such  anatomical  defects. 

The  medico-legal  bearing  of  the  fact  of  asymmetry  has  been  called 
attention  to  by  Hunt  in  the  paper  already  referred  to. 

Hypertrophy  of  the  limbs  may  occur  from  two  causes,  from  disease 
of  the  vessels  or  from  a  congenital  tendency. 


CHAPTER  XXI. 

TALIPES    EQUINUS   AND   TALIPES   CALCANEUS. 

Talipes  equinus. — Varieties  and  symptoms. — "Contracted  foot"  ("non-deforming 
club-foot"). — Treatment. — Talipes  calcaneus. — Varieties  and  symptoms. — Treat- 
ment.— Pes  cavus  (pes  arcuatus). 


Talipes  Equinus. 

Talipes  equinus  is  the  name  given  to  a  condition  in  which  the  foot 
is  held  in  a  position  of  plantar  flexion  and  cannot  be  flexed  dorsally  to 
the  proper  extent.  It  is  known  also  as  pes  equinus,  horse  heel,  pied  bot 
equin,  Pferdefuss,  and  Spitzfuss. 

Varieties  and  Symptoms. — As  a  congenital  deformity,  talipes  equinus 
is  the  greatest  of  rarities  but  its  existence  is  well  established.  As  an  ac- 
quired deformity  it  is  very  common,  especially  in  its  lighter  degrees. 


Fig.  557. 
Figs.  556,  557.  and  558.— Talipes  Equinus. 


Fig.  558. 


In  the  acquired  form  all  degrees  are  met,  from  a  condition  in  which 
the  foot  cannot  be  flexed  beyond  a  right  angle  to  one  in  which  the  foot 
and  leg  are  nearly  in  a  continuous  line.  The  deformity,  in  the  lighter 
degrees,  is  one  of  less  importance  than  the  other  forms  of  talipes. 


TALIPES   EQUINUS   AND   TALIPES   CALCANEUS.  5  99 

A  slight  degree  of  this  affection  may  be  enough  to  cause  a  limp  in 
walking,  as  in  carrying  the  leg  back  at  the  end  of  the  step  the  foot  must 
be  bent  more  than  to  a  right  angle. 

The  structural  changes  in  talipes  equinus  are  slight.  In  a  large  num- 
ber there  is  simply  a  shortening  in  the  Achilles  tendon  muscles,  with  a 
consequent  alteration  in  the  shape  or  relation  of  the  bones  of  the  foot. 
Some  cases,  however,  are  due  less  to  the  raising  of  the  calcaneum  than 
to  a  depression  of  the  head  of  the  astragalus,  which  may  be  depressed 
nearly  in  a  vertical  line,  and  the  arch  of  the  foot  increased  by  a  strong 
flexion  at  the  medio-tarsal  joint. 

The  causes  of  acquired  talipes  equinus  are  as  follows : 

(1)  Infantile  paralysis  of  the  anterior  muscles  of  the  leg. 

(2)  Cerebral  (spastic)  paralysis,  hemiplegia,  pseudo-hypertrophic 
paralysis,  and  similar  affections  causing  either  loss  of  power  in  the 
anterior  muscles  of  the  leg  or  an  overbalancing  of  these  muscles  by  the 
contraction  of  the  posterior  group. 

(3)  Shortening  of  the  leg  after  joint  disease  or  fracture  may  lead  to 
an  adaptive  talipes  equinus  which  serves  to  make  the  legs  of  equal 
length. 

(4)  Disease  of  the  ankle-joint  may  have  talipes  equinus  for  a  symp- 
tom. 

(5)  Long  confinement  to  bed  may  cause  a  talipes  equinus,  which  is 
merely  a  result  of  the  long-continued  plantar  flexion  of  the  feet. 

(6)  Fractures  may  result  in  talipes  equinus  either  from  injury  to  the 
ankle-joint  or  from  fixation  during  repair  in  a  plantar  flexed  position. 

(7)  Hysteria  may  be  a  cause. 

(8)  The  contraction  caused  by  posterior  cicatrices  or  the  loss  of  power 
due  to  division  or  injury  of  the  anterior  muscles  and  tendons  of  the  leg 
may  cause  the  deformity. 

In  the  severer  forms  there  is  a  marked  projection  on  the  dorsum  of 
the  foot  formed  at  the  site  of  the  calcaneo-cuboid  and  astragalo-scaphoid 
articulations.  As  locomotion  occurs  only  on  the  ball  of  the  foot,  this 
part  becomes  abnormally  wide,  and  in  time  the  plantar  fascia  contracts 
and  resists  the  reduction  of  the  malposition. 

In  very  severe  cases  the  foot  is  bent  on  itself,  so  that  the  sole  is 
directed  upward  and  backward,  and  locomotion  takes  place  on  the  dorsum 
of  the  foot. 

The  spastic  form  is  most  commonly  met  in  spastic  paralysis  or  after 
hemiplegia.  As  this  is  due  to  the  contraction  of  the  muscles  of  the 
tendo  Achillis,  the  position  of  the  foot  in  this  differs  from  that  following 
paralysis.  The  heel,  in  the  spasmodic  form,  is  drawn  upward  and  the 
whole  foot  depressed  in  consequence.  There  is,  therefore,  less  tendency 
to  the  formation  of  an  angle  in  the  medio-tarsal  or  tarso-metatarsal 
joints. 


600  ORTHOPEDIC   SURGERY. 

The  form  often  met  in  shortened  limbs,  as  after  recovering  from  hip 
disease,  fracture,  etc.,  is  the  result  of  the  maintenance  of  the  foot  for  a 
long  time  in  a  partially  extended  position,  in  the  act  of  walking  and 
standing.  In  these  cases  it  is  a  compensatory  arrangement,  inasmuch  as 
it  tends  to  keep  the  pelvis  level,  and  not  to  be  regarded  as  objectionable 
except  in  its  appearance. 

The  detection  of  talipes  equinus  is  so  simple  a  matter  that  it  scarcely 
needs  description.  The  normal  foot  should  be  capable  of  flexion  some- 
what beyond  a  right  angie,  and  any  cause  which  restricts  this  flexion  is  a 
degree  of  talipes  equinus. 

"  Contracted  Foot"  (" N on- Deforming  Glub-Foot ") .—One  form  of  a 
slight  degree  of  talipes  equinus  deserves  separate  consideration.  It  is 
characterized  b}r  a  slight  or  moderate  degree  of  limitation  of  the  normal 
dorsal  flexion  of  the  foot.  Shaffer  described  it  under  the  name  of  "  non- 
deforming  club-foot, "  and  it  has  also  been  spoken  of  as  "  contracted  foot."  ' 
Apparently  it  is  due  to  a  contraction,  often  temporary,  of  the  posterior 
muscles  of  the  leg,  chiefly  the  gastrocnemius,  or  the  muscles  of  the  sole 
of  the  foot.  It  may  occur  in  flat-foot,  the  weakened  foot,  and  in  similar 
conditions  in  which  it  is  apparently  due  to  irritation  and  possibly  is  reflex 
in  character.  The  writers  have  not  in  most  cases  been  able  to  regard  it 
as  a  causative  factor  in  fiat-foot,  as  advanced  by  Shaffer. 

It  is  often  associated  with  metatarsalgia,  possibly  as  a  causative 
factor,  possibly  as  a  result  of  irritation  from  the  foot.  It  exists  often 
in  sciatica  when  flexion  of  the  foot  beyond  a  right  angle  is  not  only 
restricted  but  painful.  It  sometimes  is  found  in  elderly  persons  in 
whom  it  seems  to  be  the  result  of  stiffening  and  loss  of  elasticity  in  the 
posterior  muscles.  It  exists  occasionally  in  hysterical  persons,  chiefly 
in  women,  without  further  obvious  cause.  It  may  be  found  in  adults 
or  children  apparently  perfectly  healthy  in  whom  no  demonstrable  cause 
for  it  exists.     It  is  found  often  after  sprains  of  the  ankle. 

As  it  is  not  an  obvious  deformity  it  often  escapes  recognition.  The 
most  common  symptoms  associated  with  this  slight  degree  of  talipes 
equinus  consist  in  cramps  in  the  calves,  especially  at  night,  heaviness 
and  stiffness  in  the  feet  in  walking,  tenderness  in  the  plantar  fascia,  and 
often  a  feeling  of  tension  in  the  back  of  the  leg  and  thigh.  Backache  is 
not  an  uncommon  accompaniment.  All  of  these  symptoms  seem  to  be 
aggravated  by  the  use  of  the  feet. 

On  inspection  the  arch  of  the  foot  is  seen  to  be  unusually  high,  the 
toes  maybe  somewhat  "clawed, "  dorsal  flexion  of  the  foot  is  limited, 
and  when  the  foot  is  brought  to  a  right  angle  a  tense  and  tender  band  in 
the  plantar  fascia  is  generally  found.  The  examination  for  dorsal  flexion 
should  of  course  be  made  with  the  leg  fully  extended  at  the  knee. 

1  Park's  "System  of  Surgery,"  vol.  ii.,  article  "Orthopedic  Surgery." 


TALIPES   EQUINUS   AND    TALIPES    CALCANEUS.  601 

A  condition  of  limited  dorsal  flexion  of  the  foot  associated  with  art 
unusually  high  arch  exists,  however,  in  certain  persons  without  giving 
rise  to  symptoms. 

Treatment. — The  treatment  of  the  mildest  variety,  just  described 
under  the  name  of  "contracted  foot,"  consists  in  seeking  for  the  cause  of 
it  and  relieving  it  when  possible.  If  the  foot  is  weak  it  should  be  prop- 
erly supported  in  a  correct  position,  as  will  be  described  in  the  following 
chapter.  It  sometimes  affords  relief  to  support  a  troublesome  high  arch 
by  a  high  shank  of  the  shoe  or  by  felt  pads  or  steel  plates.  The  dorsal 
flexion  of  the  foot  may  often  be  restored,  in  part  at  least,  by  means  of  the 
shoe  devised  by  Shaffer,  which  by  means  of  a  geared  joint  at  the  ankle 
exerts  powerful  pressure  in  the  direction  of  dorsal  flexion.  The  shoe 
consists  of  a  sole  plate,  two  uprights,  and  a  posterior  band.  The  foot 
is  secured  to  the  foot  plate,  and  dorsal  flexion  of  any  degree  is  secured  by 
turning  the  key  at  the  ankle,  by  which  the  sole  plate  is  flexed  on  the 
uprights.  In  the  use  of  the  apparatus  Shaffer  advises  intermittent  trac- 
tion of  a  force  suited  to  each  case.  The  apparatus  should  not  be  used 
to  exert  extreme  force,  but  only  a  degree  comfortable  to  the  patient. 
This  method  of  treatment  is  of  value  in  relieving  the  symptoms  in  many 
of  the  cases.  In  certain  cases  the  symptoms  return  shortly  after  the  ces- 
sation of  treatment.  In  others  the  benefit  seems  permanent.  In  anterior 
metatarsalgia  the  increase  of  dorsal  flexibility  is  often  of  benefit  in  con- 
nection with  the  other  treatment.  The  method  is  useful  only  in  very 
slight  cases  of  talipes  equinus  in  which  dorsal  flexion  is  limited  at  about 
a  right  angle. 

A  simple  appliance  may  be  made  by  securing  the  patient's  leg  to  a 
flat,  smooth  piece  of  board,  by  means  of  strips  of  adhesive  plaster  from 
the  sides  of  the  leg  to  the  bottom  of  the  board.  If  this  board  is  longer 
than  the  foot  and  is  furnished  with  a  strap  secured  to  the  projecting  end 
of  the  board  and  to  a  buckle  secured  to  the  leg  by  adhesive  plaster, 
stretching  the  tendo  Achillis  can  be  accomplished  by  tightening  the 
strap. 

When  talipes  equinus  of  any  but  the  slightest  grade  exists  the  only 
treatment  consists  of  tenotomy  of  the  tendo  Achillis,  and  of  the  plantar 
fascia  if  that  is  contracted  also. 

When  the  deformity  is  due  to  spastic  paralysis,  simple  tenotomy  of 
the  heel  tendon  is  sufficient;  when  there  is  contraction  of  the  plantar 
fascia,  that  should  be  cut  before  tenotomy  of  the  tendo  Achillis  is  done, 
as  the  contracted  heel  tendon  affords  useful  counter-pressure  in  straight- 
ening the  arch  of  the  foot  after  division  of  the  fascia. 

The  deformity  should  be  at  once  corrected  after  tenotomy  and  a 
plaster-of -Paris  bandage  applied.  If  a  retention  appliance  is  required 
after  operation,  the  usual  form  of  club-foot  shoe,  with  the  ankle-joint 
arranged  to  stop  extension  at  a  right  angle,  will  be  found  to  be  effectual 


602  ORTHOPEDIC    SURGERY. 

and  simple.  Or  a  simple  foot  piece  joined  to  two  uprights  and  a  pos- 
terior band  may  be  used  which  is  jointed  in  the  same  way  at  the  ankle. 
This  prevents  the  foot  from  rolling  in  or  out  and  thus  makes  the  act  of 
walking  a  force  to  pull  upon  the  tendo  Achillis  at  each  step. 

In  extremely  severe  cases  a  wedge-shaped  osteotomy  of  the  tarsus 
might  be  required  for  rectification,  but  this  would  be  very  unusual. 

Talipes  Calcaneus. 

Talipes  calcaneus  is  the  name  applied  to  a  condition  in  which  the  foot 
is  held  in  a  position  of  dorsal  flexion.  It  is  known  also  as  pes  calcaneus, 
pied  bot  calcaneen,  pied  bot  tabes,  and  Hackenfuss. 

Varieties  and  Symptoms. — The  deformity  may  exist  alone  or  in  con- 
nection with  valgus,  in  which  case  it  is  known  as  talipes  calcaneo-valgus. 
It  exists  occasionally  as  a  congenital  deformity  in  varying  degrees.  It 
may  be  noticed  only  as  a  slight  prominence  of  the  heel  or  it  may  be  so 
severe  that  the  dorsum  of  the  foot  lies  practically  against  the  shin.  No 
better  explanation  has  been  given  for  its  existence  than  is  the  case  in 
other  congenital  deformities. 

Acquired  talipes  calcaneus  is  most  often  due  to  paralysis  of  the  mus- 
cles of  the  calf  of  the  leg  due  to  anterior  poliomyelitis.  It  may  also 
occur  in  chronic  disease  of  the  ankle  as  a  result  of  muscular  irritability. 
It  exists  sometimes  in  hysteria.  It  may  result  from  rupture  or  division 
of  the  posterior  muscles  of  the  leg  and  from  anterior  cicatrices. 

Ankylosis  of  the  ankle  in  a  deformed  position  has  been  recorded  in 
one  case.1 

The  deformity  is  obvious  on  inspection  and  requires  no  description; 
the  patient  of  course  walks  upon  the  heel. 

Treatment. — In  congenital  cases  manipulation  with  daily  attempts  at 
rectification  by  the  parents  is  sufficient  to  correct  the  deformity  except  in 
the  severer  cases  in  which  the  application  of  a  series  of  corrective  plaster 
bandages  may  be  necessary.  Tenotomy  of  the  anterior  tendons  is  rarely 
necessary. 

When  the  foot  has  been  reduced  to  the  normal  position,  and  the 
motion  extended  to  the  normal  limits,  a  retention  shoe  may  be  applied^ 
but  in  slight  cases  this  is  not  necessary. 

For  retention,  a  steel  sole  plate  and  upright,  with  a  stop  at  the 
ankle-joint  so  as  to  prevent  flexion  beyond  a  right  angle,  is  of  value. 

The  treatment  of  talipes  calcaneus  due  to  infantile  paralysis  has 
already  been  considered. 

1  Hoffa:  "Orthopadische  Chirurgie." 


TALIPES   EQUINUS   AND   TALIPES   CALCANEUS. 


eo'i 


Pes  Cavus. 

(Pes  Arcuatus.) — In  this  deformity  the  anterior  part  of  the  foot 
is  drawn  backward  and  the  arch  increased.  All  degrees  of  severity 
are  found,  even  to  a  condition  in  which  the  ball  of  the  foot  and  heel 


FIG.  559.  Fig.  560. 

Figs.  559  and  560.— Biggs'  Appliance  for  Pes  Cavus. 

are  in  contact;  and  the  arch  of  the  foot  is  converted  into  a  deep  sulcus. 
In  an  exaggerated  degree  it  is  the  condition  of  the  feet  of  high-caste 
Chinese  women.  This  form  is  in  reality  a  variety  of  the  calcaneus,  to 
which  the  cavus  has  been  added. 

Three  forms  of  pes  cavus  are  recognized.     The  first  is  due  to  the  con- 
traction of  the  peroneus  longus;  and  the  resulting  deformity  is  in  conse- 


Fig.  561.— Diagram  of  Position  of  Bones  in  Chinese  Lady's  Foot. 

quence  of  the  approximation  of  its  insertion  and  the  heel.  The  second 
variety  is  the  result  of  paralysis  of  the  gastrocnemius  and  soleus  muscles. 
The  sole  of  the  foot  is  lowered,  and  by  the  action  of  the  long  flexors  on 
the  anterior  part  a  cavus  foot  is  developed.     There  may  be  complicated 


604  ORTHOPEDIC   SURGERY. 

with  this  a  varus  or  valgus  distortion.  The  third  form  may  be  acquired, 
but  is  usually  congenital.  It  has  been  called  by  Duchenne  "  Griffe-pied- 
creux. "  The  condition  results  from  a  marked  depression  of  the  heads  of 
the  metatarsal  bones  with  a  forced  extension  of  the  first  phalanges  and 
a  flexion  of  the  last.  The  origin  of  the  affection  is  in  a  paralysis  of  the 
interossei  and  lumbricoid  muscles,  and  of  those  muscles  which  are  in- 
serted into  the  sesamoid  bones  of  the  great  toe. 

Treatment. — It  is  difficult  to  correct  the  deformity  of  pes  cavus  by 
mechanical  appliances ;  the  common  form  of  these  consists  in  a  steel  sole 
plate  with  a  constricting  band  over  the  head  of  the  astragalus. 

An  ordinary  steel  sole  plate  made  from  a  cast  of  the  corrected  foot 
and  inserted  in  the  shoe  is  of  assistance. 


CHAPTER  XXII. 


FLAT-FOOT   AND    OTHER    AFFECTIONS    OF    THE    FEET. 

The  weakened  foot.  —  Anatomy.  — Flat-foot.  —  Pathological  anatomy. — (  ausation. 
— Symptoms. — Diagnosis. — Prognosis.  —Treatment. — Corrective. —  Mechanical. 
—Morton's  disease. — Hallux  valgus. — Hallux  varus.— Hallux  rigidus.  —  Hammer 
toe. — Deviation  of  the  small  toes. — Miscellaneous  conditions. 

Owing  to  the  almost  universal  use  of  shoes  and  the  consequent 
cramping  of  the  feet,  it  is  necessary,  for  a  study  of  the  normal  foot,  to 
examine  the  feet  of  infants  and  of  moccasin  or  sandal-wearing  races. 

In  young  infants  of 
normal  nutrition  the  foot 
seems  shorter  and  thicker 
than  that  of  the  adult  or 
older  child.  It  also  ap- 
pears on  superficial  exami- 
nation to  have  little  or  no 
arch. 


Fig.  562.— Left  Foot  of  Child  Eighteen 
Months  Old.    (Dane.) 


Fir.  563.— Same,  Section  at  Mediotarsal  Joint.     (Dane.) 


Dane  has  shown  by  measurements  of  the  height  of  the  scaphoid  above 
the  level  of  the  sole  and  by  hardened  sections  of  the  feet  of  infants  that 
the  bony  arch  of  the  child's  foot  is  not  flattened  at  birth  but  that  the 
apparent  flatness  is  due  to  a  pad  of  fat  placed  under  the  arch  of  the 
foot. 

If  the  foot  of  a  young  infant  is  examined  it  will  be  seen  that  there  is 
muscular  power  in  the  movement  of  all  of  the  toes.      The  great  toe  can 


606 


ORTHOPEDIC    SURGERY. 


voluntarily  be  drawn  to  the  inner  side,  and  the  fifth  toe  can  be  drawn  to 
the  outer  side  by  voluntary  muscular  exertion.  The  toes 
can  be  flexed  readily.  The  second  toe  is,  when  stretched 
to  its  full  length,  frequently  longer  than  the  first.  The 
third  is  of  the  same  length  as  the  first,  the  fourth  is 
somewhat  shorter,  and  the  fifth,  though  shorter,  is  but 
slightly  so.  1ST  one  of  the  toes  remain  permanently  curled, 
though  when  in  a  relaxed  condition  the  terminal  pha- 
lanx drops  somewhat  and  the  smaller  toes  curl.  A  sep- 
aration between  the  first  and  second  toe  is  normal.  When 
the    muscles  are  active  the  great    toe  is  drawn  to  the 

inner  side  frequently.      The  line  of  the  extremities  of  the  toes  presents 


Fig.  564.— Ordinary 
Type  of  Foot  Imprint 
in  Infants. 


Fig.  565.— Egyptian  Statue,  British  Museum,  Showing  Straightness  of  Toes 


a  gradual  curve  with  the  greatest  forward  convexity  at  the  tip  of  the 
second  toe.  The  line  of  the  inner  edge  of  the  foot  is  always  straight 
except  when  there  is  contraction  of  the  muscles. 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


607 


If  the  undisturbed  adult  foot  which  has  never  worn  shoes  be  exam- 
ined, it  will  be  found  to  present  many  of  the  characteristics  of  the  infant's 
foot,  but  there  is  greater  muscular  power  in  the  toes  and  foot  and  rela- 


Fig.  566.— Inter-toe  Thongs  Retaining  Sandals,  a,  Egyptian,  Japanese,  eta— between  first  and  second 
toe;  b,  Chaldean— thong  around  tlrst  toe ;  c,  Somali — around  second  toe ;  d,  Toltec — around  second  and 
third  toe ;  e,  early  Etruscan— around  second,  third,  and  fourth  toes. 

tively  less  fatty  tissue.      The  flexibility  of  the  front  of  the  foot  is  great, 
and  can  be  increased  by  training. 

The  injurious  effect  of  shoes  upon  the  foot  can  be  seen  by  comparing 
the  flexibility  of  the  front  of  the  normal  foot  of  infants  with  that  of 
the  ordinary  shoe-wearing  individual.  It  will  be  found  that  the  flexi- 
bility of  the  toes  is  impaired  and  the  power  voluntarily  to  adduct  the 
great  toe  and  separate  the  fourth  and  fifth  toes  is  either  lost  or  mate- 


/> 


Fig.  567.— Feet  as  Seen  among  Shoe-wearing  People  with  Little  Distor-  Fig.  568.— Greek  Sandal- 

tion.    a.  Adult— first  and  fifth  toe  slightly  crowded  by  shoes;   b,  infant—  with  Intertoe  Straps,  Side 

toes  extended  by  muscular  action ;    c,  infant— muscles  relaxed  ;   d,  slight  Straps  Compressing  Little 

crowding  of  toes— from  shoe— in  a  child.  Toe. 

rially  diminished.     The  front  of  the  foot  is  compressed  by  shoes  and 
its  functional  power  lessened.' 

The  effect  of  impairment  of  the  muscular  power  of  the  muscles  of  the 

1  An  examination  of  the  foot  as  represented  in  art  shows  that  the  foot,  though  im- 
perfectly modelled,  is  near  to  the  normal  type  in  Egyptian  sculpture  ;  is  nearly  nor- 
mal in  Greek  art,  except  in  the  distortion  of  the  fifth  toe,  from  the  cross  sandal  strap  ; 
in  the  art  of  the  Renaissance  the  distortion  of  the  first  toe,  known  as  hallux  valgus, 
and  a  weakened  position  of  the  foot  are  frequently  seen,  and  this  is  also  true  of 
modern  sculpture  (Orthop.  Trans.,  vol.  x.,  p.  148). 


608 


ORTHOPEDIC   SURGERY. 


sole    of  the  foot  and  the  muscles  controlling  the  toes  is    to  develop  a 
pathological  condition  which  may  be  described  as  weakened  foot. 


1-iG.  5U9. — Table  with  Glass  Top  for  Examining  Feet. 


Fig.  570.— Glass  Table  for  Examining,  in  Use  with  Minor. 

The  Weakened  Foot. 

By  the  weakened  foot  is  meant  a  foot  which  in  ordinary  standing 
habitually  assumes  that  faulty  attitude  in  which  it  rolls  over  inward,  the 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    609 

inner  malleolus  projects,  and  abduction  of  the  front  part  of  the  foot  oc- 
curs. Up  to  a  certain  limit  this  movement  occurs  in  the  normal  foot; 
beyond  this  limit  it  must  be  regarded  as  pathological,  and  is  likely  to  be 
attended  by  symptoms  of  pain  and  disability.  This  condition  can  be 
observed  if  the  patient  suffering  from  weakened  foot  stands  on  a  piece  of 
plate  glass  and  the  surgeon,  looking  into  a  mirror  placed  obliquely  under- 
neath, sees  the  contact  of  the  foot  with  the  glass  as  a  dead  white  area 
where  the  pressure  is  greatest,  and  as  a  less  ansemic  area  where  the  press- 
ure is  less.     There  is  no  difficulty  in  distinguishing  the  line  of  contact 


Fig.  571.— Type  of  Tracing  Described  as  Normal. 

of  the  foot  with  the  glass.  In  the  normal  foot  not  bearing  excessive 
weight,  the  inner  border  of  the  great  toe,  the  inner  malleolus,  and  the 
inner  condyle  of  the  femur  should  all  be  in  the  same  vertical  place.  A 
certain  amount  of  yielding  is  normal  under  weight-bearing,  but  in  the 
weak  or  overweighted  foot  the  foot,  by  this  movement  carried  to  excess, 
is  displaced  too  much  outward  in  its  relation  to  the  leg. 

When  the  whole  weight  of  the  body  is  thrown  upon  a  limb,  the  foot 
being  planted  firmly  upon  the  ground,  the  whole  leg  rotates  inward  at 
the  hip.  The  inner  malleolus  moves  inward,  downward,  and  backward; 
the  outer  malleolus  forward ;  the  whole  foot  rolls  over  somewhat  to  the 
inner  side.  ™-  

This  movement  is  made  possible  (while  the  heel  and  front  of  the  foot 
39 


610 


ORTHOPEDIC   SURGERY. 


are  firmly  supporting  weight)  by 
When  the  muscles  and  liaranients 


Pig.  572.— Diagram  Showing  Composite 
Character  ':  of  Imprint  Tracings.  Dotted 
line  shows  weakened  position. 


motion  at  the  medio-tarsal  articulation. 

checking  this  motion  are  weakened,  the 
movement  at  the  medio-tarsal  articu- 
lation becomes  exaggerated  and  the 
anaemic  portion  seen  in  the  mirror  as 
the  patient  stands  on  glass  changes 
in  shape  from  that  seen  in  a  normal 
foot. 

The  inward  rolling  of  the  foot  is 
also  shown  by  a  foot  impression  upon 
paper  blackened  by  smoke,  though 
with  less  accuracy  than  when  seen  as 
described  in  the  mirror.  The  impres- 
sion of  the  foot  bearing  but  little 
weight  and  that  of  one  bearing  in- 
creased weight  differ  normally,  but 
the  difference  is  greater  in  a  foot  in 
which  the  muscles  are  weakened. 

When  this  position  consequent 
upon  a  weakened  condition  of  the 
foot  is  constantly  taken  by  prolonged 
standing,  it  produces  an  abnormal 
strain  not  only  on  the  muscles  and 
ligaments  of  the  foot  but  upon  other 
muscles,  as  has  been  shown  by  Dane, ' 
who  formulates  his  conclusions  as  fol- 
lows: 

"1.  In  'pronation  of  the  foot'  the 
greater  part  of  the  foot  remains  sta- 
tionary and  the  leg  rotates  upon  it. 


Fig.  573.— Outline  Drawing  (from  Photograph), 
Showing  Inward  Excursion  of  Internal  Malleolus 
in  Pronation. 


Fig.  574.— Outline  Drawing  (from  Photograph) 
in  Normal  and  Pronated  Position,  Showing  For- 
ward Excursion  of  Mark  over  External  Malleolus 
in  the  Pronated  Position. 


1  John  Dane:  Orth.  Trans.,  1897. 


PLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    611 

"  2.  In  addition  to  the  generally  recognized  motion  of  the  malleoli 
inward  and  slightly  downward,  the  normal  outward  rotation  of  the  tibia 
and  fibula  is  replaced  by  an  exaggerated  rotation  inward  which  takes 
place  about  a  nearly  vertical  axis  located  near  the  inner  border  of  the 
tibia. 

"3.  These  changes  acting  together  produce  an  alteration  in  the 
obliquity  of  the  axis  of  flexion  of  the  ankle-joints  sufficient  to  destroy 
the  mechanism  by  which  the  normal  joints  are  enabled  to  support  the 
body  weight  with  a  minimum  of  muscular  exertion.  As  a  consequence, 
flexion  must  be  prevented  and  equilibrium  maintained  wholly  by  muscu- 
lar force,  which  soon  leads  to  irritation  and  fatigue  of  all  the  muscles  of 
the  lower  leg,  and  especially  of  the  peroneus  longus. 

"  4.  This  inversed  rotation  of  the  tibia  interferes  to  a  great  extent 
with  the  operation  of  the  mechanism  by  which  complete  extension  of  the 
knee  should  lock  the  joint  and  render  it  proof  against  the  constant  ten- 
dency of  the  body  weight  to  flex  it.  The  knee  must,  therefore,  in  sub- 
jects with  pronated  feet,  be  kept  in  extension  by  a  constant  exercise  of 
muscular  force  which  results  in  the  fatigue  and  tendency  to  tonic  spasm 
of  the  muscles  of  the  thigh.  This  is  shown  also  by  the  extreme  tender- 
ness often  found  over  the  point  of  insertion  of  the  internal  hamstring 
muscles  on  the  inner  tuberosity  of  the  tibia. 

"5.  Owing  to  the  constant  attempt  of  the  muscles  on  the  outer 
side  of  the  thigh  to  prevent  the  internal  rotation  of  the  lower  part 
of  the  leg  they  are  commonly  found  to  be  tense  and  sensitive  to  press- 
ure. 

"  6.  To  try  and  compensate  for  this  inversed  rotation  of  the  tibia  and 
fibula  there  is  an  exaggerated  inward  rotation  of  the  femur.  This  in  its 
turn  overstretches  the  external  rotators  of  the  hip,  as  shown  by  sensi- 
tiveness to  pressure  and  tonic  spasm  of  the  glutei,  and  tenderness  over 
the  points  of  exit  of  the  sacral  nerves. 

"7.  Lastly,  this  explanation  is  wholly  in  accord  with  the  clinical  fact 
that  when  we  have,  by  means  of  efficient  mechanical  support,  prevented 
'  pronation  of  the  foot, '  we  have  relieved  the  pains  in  the  calf,  the  knee, 
and  the  hip." 

Anatomy. — Investigations  of  the  anatomical  changes  in  the  positions 
of  the  bones  of  the  foot  involved  as  weight  is  thrown  upon  the  limb 
have  been  made  by  a  number  of  observers,  especially  by  ^leyer1  and 
Golobiewski.2  To  illustrate  this  still  further,  skiagraphic  observations 
were  made  by  one  of  the  writers.3  The  feet  were  photographed  in  two 
or  three  directions,  from  the  inside,  from  above,  and  from  the  outside; 


1  "Statik  una  Mechanik  des  nienschl.  Fusses." 

2Zeit.  f.  orth.  Chir.,  1894,  iii.,  243. 

3R.  W.  Lovett  and  F.  J.  Cotton :  Trans.  Am.  Orth.  Assn.,  vol.  xi. 


612 


ORTHOPEDIC   SURGERY. 


when  correction  was  possible,  the  same  foot  was  photographed  in  the 
two  positions  of  supination  and  pronation  (that  is  in  the  normal  and 
weakened  position) . 

In  photographing  the  two  positions  the  foot  was  allowed  to  sink  or 
was  corrected  to  the  required  position,  and  a  fresh  plate  was  adjusted 


Fig.  575.— a  very  Mobile  Foot.    Full  line  shows  position  of  supination  ;  dotted  line  that  of  voluntary 

pronation.    No  symptoms. 

and  exposed  in  the  same  place,  neither  the  sole  of  the  foot  nor  the  tube 
being  moved.     In  all  cases  a  definite  measured  distance  of  the  tube  from 


Fig.  576.— A  Painful  Weakened  Foot  (X-ray  Tracings).    Dotted  line  shows  standing  position  ;  full  line 

that  of  voluntary  correction. 


the  plate  was  used,  and  the  foot  was  placed  in  constant  relation  to  both. 
For  the  lateral  views  the  tube  was  placed  at  the  height  of  the  astragalus ; 
for  the  views  from  above,  the  centre  of  the  tube  was  placed  directly  over 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


613 


the  centre  of  the  front  edge  of  the  plate.  The  views  were  taken  with  the 
foot  in  a  position  of  slight  toeing-out,  and  as  nearly  as  possible  with  each 
foot  bearing  an  equal  part  of  the  body  weight. 

In  this  way  there  was  obtained  a  series  of  negatives  in  which  the 
error  of  distortion  seems  to  have  been  reduced  to  a  minimum ;  for  what- 
ever distortion  was  present,  under  this  constant  relation  of  distance  and 


^-'-V  ."- 


Fig.  577.— A  Painful  Pronated  Foot  (X-ray- 
Tracings).  Standing  position  shown  in  dotted 
line :  full  line  shows  voluntary  correction. 


Fig.  578.— Voluntary  Protection  against  Strain. 
Normal  standing  position.     (Whitman.) 


angle,  must  be  approximately  reproduced  in  each  and  every  plate.  The 
plates  were  compared  by  overlaying  accurate  tracings  of  the  negatives, 
a  method  which  proved  much  more  serviceable  than  the  use  of  prints,  or 
of  the  negatives  themselves.  Forty-four  negatives  were  taken,  of  which 
forty-one  proved  available  for  comparisons. 

It  was  found  that  a  rotation  of  the  whole  foot  takes  place  beneath  the 
astragalus  toward  the  position  of  valgus.  This  is  seen  on  the  a-ray  plate 
of  the  lateral  view  by  comparison  of  the  relations,  in  the  two  positions, 
of  scaphoid  and  cuboid,  and  is  also  obvious  in  the  view  from  above. 
The  valgus  rotation  of  the  calcis  is  best  seen  in  side  view  by  comparison 
of  the  relative  positions  of  the  sustentaculum  tali  and  the  line  of  the  up- 
per surface  of  the  calcis.     The  maximum  extent  of  this  rotation  was  in 


614 


ORTHOPEDIC    SURGERY. 


one  case  about  fourteen  degrees.     This  was  readily  determined  by  setting 
up  dry  bones  to  correspond  to  the  positions  indicated  by  the  tracings. 

The  astragalus  so  rotates  in  pronation  that  its  head  moves  inward  and 
backward,  its  body  and  outer  portion  outward  and  forward.  This  is 
obvious  in  the  bone  itself,  and  is  accompanied  by  the  very  obvious 
change  in  position  of  the  malleoli,  which,  of  course,  move  with  it  in  this 


Fig.  579.— Voluntary  Adduction.    (Whitman.) 


Fig.  580.— Voluntary  Abduction.    (Whitman.) 


rotation,  the  inner  malleolus  backward  and  the  outer  forward.  There 
is  at  the  same  time  a  plantar  flexion  of  the  astragalus  by  which  its  head 
sinks  toward  the  sole. * 

There  is  some  movement  outward  of  the  cuboid  on  the  calcis,  hard  to 
estimate  accurately  by  the  ic-ray  on  account  of  the  irregular  contours  of 
the  bones. 

Associated  with  this  is  a  movement  outward  of  the  front-foot,  taking 
place  between  the  scaphoid  and  the  astragalus,  by  which  the  head  of  the 
astragalus,  rotating  inward,  is  in  part  exposed. 

Anterior  to  this  point  no  change  of  relation  of  the  bones  is  to  be  made 


1  All  these  movements  have  been  recognized  and  described  as  occurring  in  the 
movements  of  the  normal  foot  (v.  Meyer:  "Statiku.  Mechanik  des  menschi.  Fusses", 
Golobiewski:  Zeit.  f.  orth.  Chir.,  1894,  iii.,  243). 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


615 


out,  the  whole  front-foot,  including  scaphoid  and  cuboid,  moving  essen- 
tially en  masse. 

The  results  of  the  cc-ray  studies  were  checked  by  anatomical  observa- 
tions, not  only  of  dry  bones,  but  of  the  cadaver  in  various  stages  of  dis- 
section. The  material  placed  at  our  disposal  by  Dr.  Thomas  Dwight  did 
not  consist,  it  may  be  said,  of  dry  or  drying  specimens,  but  of  either 
alcoholic  specimens  of  ligamentous  dissections,  or  of  dissections  of  rela- 
tively fresh  cadavers,  moistened  to  a  practically  normal  flexibility.  To 
determine  the  movement  of  the  bones 
one  upon  the  other,  long  pins  were 
driven  into  each  of  the  various  bones, 
and,  with  the  foot  bearing  weight,  the 
positions  of  pronation  and  supination 
were  produced.  The  movements  of 
the  free  ends  of  the  pins  gave  a  cor- 
rect means  of  determining  the  move- 
ments taking  place  between  the 
bones,  and  a  very  close  correspond- 
ence in  detail  was  found  with  the 
results  of  the  cc-ray  photographs. 
Only  in  one  respect  was  there  a  dif- 
ference worthy  of  note:  in  the  ca- 
daver less  valgus  rotation  of  the 
calcis  and  more  motion  between  the 
cuboid  and  os  calcis  were  found 
under  similar  conditions  than  the 
cc-ray  photographs  had  led  us  to 
expect. 

The  abduction  of  the  front-foot 
is  not  directly  dependent  on  the  rota- 
tion of  the  calcis,  but  rather  upon 
the  horizontal  rotation  of  the  astrag- 
alus. The  head  of  the  astragalus,  which  is  roughly  spherical,  moves 
in  a  ball-and-socket  joint  formed  by  the  sustentaculum  tali,  the  calcaneo- 
scaphoid  ligament,  and  the  scaphoid.  This  allows  of  free  movement,  but 
the  relations  of  surface  are  such  that  an  inward  rotation  of  the  head  of 
the  astragalus  (when  the  foot  is  under  weight)  determines  an  outward 
movement  of  the  scaphoid  swinging  on  the  calcaneo-scaphoid  ligament. 
Conversely,  if  the  relation  of  the  scaphoid  to  the  calcis  is  fixed,  with  the 
foot  bearing  weight,  no  inward  rotation  of  the  astragalus  is  possible.  It 
is  in  this  way  rather  than  by  supporting  the  head  of  the  astragalus  di- 
rectly, as  is  sometimes  stated,  that  the  tibialis  posticus  prevents  prona- 
tion. This  may  readily  be  shown  in  the  cadaver  by  nailing  the  tendon 
of  this  muscle  to  the  tibia,  when  pronation  is  checked.     Conversely,  in 


Fig.  581.— An  Attitude  that  Simulates  Flat-foot. 
(Whitman.) 


/ 

616  ORTHOPEDIC    SURGERY. 

some  specimens  in  which  the  muscles  and  tendons  a-re  intact,  pronation  is 
limited  by  this  muscle,  and  if  its  tendon  is  cut  or  slipped  from  its  groove, 
pronation  to  a  much  greater  extent  is  possible. 

This  somewhat  complicated  relation  between  astragalus,  scaphoid, 
and  ligaments  also  determines  the  mechanism  by  which  the  front  part  of 
the  foot-sole  is  kept  flat  to  the  ground.  As  the  foot  is  supinated,  there 
is  a  movement  downward  of  the  scaphoid  over  the  head  of  the  astragalus 
as  well  as  the  movement  inward  just  described.  When  the  foot  is  rolled 
outward  in  supination,  this  plantar  flexion  of  scaphoid,  cuneiform,  and 
inner  metatarsals  acts  to  compensate,  and  the  inner  side  of  the  ball  of  the 
foot  still  remains  in  contact  with  the  ground.  This  compensation  has  a 
practical  bearing. 

It  is  to  be  noted  that  the  astragalus  has  no  muscular  insertions  and 
acts  simply  as  a  transmitter,  and  the  sole  transmitter,  of  the  body  weight. 
Once  movement  of  the  astragalus  is  permitted  by  the  muscles,  its  move- 
ments and  the  movements  of  the  tarsal  bones  beneath  it  are  determined 
only  by  the  relations  of  the  joint  surfaces — though  ligaments  may  limit 
their  extent. 

To  sum  up,  the  movements  in  question  consist  of  the  horizontal  rota- 
tion of  the  astragalus  with  the  sinking  of  its  head,  the  rotation  in  valgus 
of  the  calcis  beneath  it,  and  the  rotation  in  valgus  and  abduction  of  the 
front-foot  as  a  whole,  occurring  between  astragalus  and  scaphoid,  calcis 
and  cuboid. 

When  the  condition  herein  described  becomes  more  developed,  struc- 
tural changes  take  place,  and  what  has  been  termed  acquired  valgus  or 
flat-foot  exists.  This  differs  from  a  weakened  foot  in  the  severity  of  the 
distortion  and  in  changes  which  take  place  in  the  impairment  of  the  elas- 
ticity of  the  ligaments,  in  changes  in  their  length,  and  in  prolonged  and 
severe  cases  in  the  shape  of  some  of  the  tarsal  bones. 

Flat-Foot. 

Flat-foot  or  talipes  valgus  is  a  deformity  characterized  by  a  marked 
pronation  of  the  foot  with  obliteration  of  its  arch.  There  is  also  abduc- 
tion of  the  front  part  of  the  foot. 

The  deformity  is  also  called  splay-foot;  in  German  Plattfuss  and  in 
French  Pied  bot  valgus,  pied  plat:  it  is  also  sometimes  called  pes  pro- 
natus. 

The  affection  is  either  congenital  or  acquired. 

Congenital  talipes  valgus  is  not  an  extremely  rare  affection.  Kilstner1 
examined,  with  regard  to  this,  150  new-born  children  consecutively,  and 
13  (8.6  per  cent)  of  these  presented  marked  congenital  flat-foot;  that  is, 

1  Archiv  f.  klin.  CMr.,  1880,  25,  p.  397. 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    617 

the  sole  of  the  foot  was  convex  and  the  whole  foot  pronated  or  rolled  out. 
Sometimes  there  is  present  congenital  calcaneo-  or  equino-valgus.  Adams 
found  42  cases  of  .congenital  valgus  in  7G4  cases  of  congenital  deformity 
of  the  feet;  in  15  others  there  was  varus  of  one  foot  and  valgus  of  the 
other.  Of  the  42  cases,  15  were  of  the  right  foot,  10  of  the  left,  and  17 
of  both. 

The  characteristics  of  the  deformity  of  congenital  valgus  are  a  strongly 
pronated.  and  abducted  position  of  the  foot  relative  to  the  axis  of  the  leg. 


Fig.  582.— Typical  Flat-foot  of  Moderate  Degree.    (Whitman.) 

Frequently  two  projections  can  be  seen  on  the  inner  side  of  the  foot  cor- 
responding to  the  head  of  the  astragalus  and  the  side  of  the  scaphoid 
bone. 

Absence  of  the  fibula  and  defective  development  of  the  external  mal- 
leolus are  congenital  deformities  at  times  associated  with  congenital 
valgus. 

Pathological  Anatomy. 

The  anatomical  changes  are  much  the  same  in  congenital  and  acquired 
talipes  valgus. 

The  bones  in  congenital  fiat-foot  even  in  severe  cases  show  but  little 
alteration  in  shape.  The  astragalus  is  turned  obliquely  to  one  side  and 
downward,  and  the  angle  of  the  articulation  faces  more  to  the  side  than 
is  normal.  The  end  of  the  os  calcis  may  be  slightly  raised.  The  scaph- 
oid is  turned  to  the  outer  side  and  is  rotated  somewhat  on  its  central 
axis,  so  that  the  outer  side  is  slightly  raised  and  the  inner  side  is  lowered 
— the  arch  of  the  foot  is  obliterated  and  the  inner  border  is  often  convex 
rather  than  concave. 

In  acquired  flat-foot  the  anatomical  changes  show  very  few  alterations 
in  the  shape  of  the  bones  in  light  cases.  The  astragalus  is  turned  obliquelv 
forward  and  downward  and  its  head  altered  in  position,  so  that  its  face 


618 


ORTHOPEDIC   SURGERY. 


is  on  the  outer  side ;  the  scaphoid  is  rotated,  and  its  outer  side  raised. 
Slight  alterations  in  the  shape  of  the  bones  are  noted,  and  in  severe 
cases  the  external  malleolus  is  somewhat  flattened  and  rounded.     In 


Fig.  583.— Rigid  Flat-foot.    (X-ray  tracing.) 


severe  cases  there  is  practically  almost  complete  dislocation  of  the  scaph- 
oid outward,  and  sometimes  there  is  a  formation  of  osseous  deposit  which 


Fig.  584.— Rigid  Flat-foot.    (X-ray  tracing.) 


prevents  the  normal  amount  of  play  between  the  scaphoid  and  astragalus. 
Alterations  in  the  shape  of  the  sustentaculum  tali  and  of  the  astragalus 
as  it  articulates  with  this  are  also  noticed. 

Of  the  ligaments  the  most  important  are  the  inferior  calcaneo-scaph- 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


619 


oid  and  the  calcaneo-astragaloid.     The  latter  of  these  does  more  to  keep 
the  "  keystone  "  of  the  arch  in  place  than  does  any  arrangement  of  its 

I 


Fig.  585.— Flat-foot. 


components.     In  the  maintenance  of  the  normal  concavity  all  the  liga- 
ments of  the  sole  of  the  foot  contribute,  but  to  a  less  extent. 


Fig.  586.— Voluntary  Plantar  Flexion  (Normal).       Fig.  587.— Voluntary  Dorsal  Flexion  (Normal). 
(Whitman.)  (Whitman.) 


620  ORTHOPEDIC   SURGERY. 

In  severe  flat-foot,  owing  to  the  change  in  the  form  of  the  bones,  there 
is  a  limitation  in  the  amount  of  motion  at  the  ankle-joint.     The  normal 


Fig.  588.— Flat-foot  Occurring  in  a  Young  Rhachitic  Child. 

amount  of  motion  which  should  be  from  76°  to  80°,  in  flat-foot  may  be 
restricted  to  45°  or  even  32°. 

Varieties  of  flat-foot  are  described  and  two  may  be  mentioned. 

The  rhachitic  variety  is  chiefly  seen  in  connection  with  other  evi- 


FlG.  589.— Flat-foot. 


dences  of  rickets.  It  may  be  found  associated  with  knock-knee,  and  the 
coincidence  is  so  common  that  it  has  been  regarded  as  one  of  the  causes 
of  knock-knee,  but  it  may  also  be  seen  in  the  very  early  stages  of  rickets 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.     621 

before  osseous  deformity  is  marked.     Rhachitic  valgus  is  seen  usually 
before  the  seventh  year. 

Traumatic  or  Inflammatory  Fiat-Foot. — The  class  of  flat-foot  due  to 
miscellaneous  causes  is  not  very  extensive  or  very  commonly  encountered. 
The  most  common  of  traumatic  causes  is  Pott's  fracture,  in  which  a  valgus 
is  the  result  of  inefficient  treatment  or  of  a  very  severe  and  intractable 
fracture.  As  a  result  of  ankle-joint  disease  accompanied  by  considerable 
destruction  of  tissue  one  sometimes  sees  very  marked  flat-foot,  which  does 
not  tend  to  grow  worse  because  there  is  generally  firm  ankylosis  in  the 
ankle;  but  the  deformity  may  be  severe.  Injury  of  the  long  peroneus 
may  give  rise  to  this  deformity  without  any  other  cause. 

Causation. 
1 

In  general  terms,  it  may  be  said  that  the  deformity  is  caused  by  a 

disproportion  between  the  weight  to  be  borne  and  the  muscular  power 

which  bears  it.     The  occurrence  of  the  deformity  is  rendered  more  likely 

by  the  shape  of  modern  boots.     The  immediate  causes  of  the  condition 

are  the  following,  in  the  order  of  their  approximate  importance : 

1.  Boots  of  improper  shape. 

2.  Weakness  or  insufficiency  of  the  muscles  resulting  from — 

(a)  Long  standing,  especially  on  hard-wood  floors. 

(b)  Eapid  growth. 

(c)  Poor  health  or  muscular  debility. 

(d)  Convalescence  from  acute  illness. 

(e)  Eapid  gain  of  weight. 

(/)  Accident  or  injury  causing  disuse  of  limb  and  subsequent  muscu- 
lar weakness. 

3.  Excessive  strain,  as  in  the  case  of  professional  strong  men  and 
jumpers. 

4.  A  shortened  condition  of  the  gastrocnemius  muscle,  as  described 
by  Shaffer.  Unless  dorsal  flexion  of  the  foot  beyond  a  right  angle  is 
possible,  it  is  impossible  for  a  person  to  complete  the  step  with  the  leg 
straight  behind  him  and  the  foot  pointing  forward.  Eversion  of  the  foot 
is  necessary,  and  a  completion  of  the  step  by  rolling  over  on  to  the  inner 
side  of  the  foot.  This,  of  course,  tends  to  produce  pronation  and  break- 
ing down  of  the  arch. 

5.  Rickets,  for  the  most  part  to  be  observed  among  children. 

6.  Infantile  paralysis. 

7.  Direct  traumatism. 

8.  Locomotor  ataxia  and  similar  organic  nervous  diseases. 

9.  Gonorrhoea!  rheumatism  and  rheumatoid  arthritis. 

The  condition  is  often  associated  with  neurasthenia,  although  it  can- 
not be  put  down  as  the  direct  result  of  it. 


622 


ORTHOPEDIC   SURGERY. 


The  most  common  cause  is  the  weakening  of  the  muscles  of  the  foot 
by  shoes.  Shoes  as  worn  by  the  leisure  class  or  by  the  class  that  gain 
their  livelihood  (as  is  the  rule  in  cities)  by  occupations  which  require 
standing  rather  than  strong  and  vigorous  walking,  compress  the  front  of 
the  foot.  This  part  of  the  foot,  from  compression  and  from  resulting 
weakness,  cannot  adapt  itself  as  greater  weight  is  thrown  upon  the  foot, 
and  the  medio-tarsal  twisting  takes  place  which  in  the  strong  bare  foot 
is  prevented  chiefly  by  the  action  of  the  tibial  muscles  and  by  the  muscles 


Fig.  590.— Weakened  Foot  without  Breaking  Down  of  Arch. 

of  the  first  metatarsal  and  its  phalanges.  People  the  front  of  whose 
feet  have  been  compressed  stand  and  walk  with  a  greater  angle  of  diver- 
gence of  the  axes  of  the  feet,  which  increases  the  danger  of  the  devel- 
opment of  the  deformity  by  bringing  greater  strain  upon  the  inner  side 
of  the  foot  and  favoring  the  inward  rolling  which  frequently  develops 
flat-foot.  Flat-foot  is  not  commonly  developed  among  moccasined  sav- 
ages who  use  their  feet  actively  as  hunters,  using  the  muscles  of  the  front 
of  the  foot  freely. 

Symptoms. 


The  physical  signs  by  which  flat-foot  is  recognized  will  be  better  ap- 
preciated by  a  glance  at  the  figures  than  by  any  amount  of  verbal  descrip- 
tion. Instead  of  the  normal  arching  upward  of  the  inner  border  of  the 
foot  this  border  either  lies  flat  on  the  ground  or  in  a  varying  degree  it 
is  less  arched  than  is  usual.  The  foot  has  the  appearance  of  being  not 
only  broad,  but  also  abnormally  long;  it  is  more  or  less  everted,  and  in 
severe  cases  the  head  of  the  astragalus  and  the  scaphoid  tubercle  form  a 
marked  bony  prominence  at  the  middle  of  the  inner  border  of  the  foot. 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


023 


Occasionally  on  inspection  it  seems  as  if  a  foot  were  normally  arched, 
but  when  a  tracing  of  the  foot  print  is  made  it  will  be  seen  that  the  inner 
border  of  the  foot  is  less  a  curved  line  than  it  should  be.  The  inner 
malleolus  is  more  prominent  than  it  should  be,  and,  of  course,  nearer 
to  the  ground — the  whole  foot,  in  fact,  is  in  an  altered  relation  to  the 
axis  of  the  leg.     It  seems  to  have  been  distinctly  displaced  outward. 

In  severe  cases  the  inner  border  of  the  foot  presents  a  convex  outline 


Fig.  591.— Improper  Attitude  of  Eversion  of  the 
Feet.    (Whitman.) 


Fig.  592.— Involuntary   Adduction  of  the  Right 
Fore-foot  in  the  Proper  Attitude.    (Whitman.) 


and  the  outer  border  is  raised  so  that  the  weight  is  transmitted  more  im- 
properly than  ever.  This  elevation  of  the  outer  border  of  the  foot  is  the 
result  of  a  contraction  of  the  peronei  muscles  and  ultimately  of  the  gas- 
trocnemius, the  result  of  long-continued  reflex  irritation. 

Manipulation  of  the  foot  is  sometimes  not  attended  with  pain,  at 
other  times  any  attempt  at  replacement  is  very  uncomfortable  to  the  pa- 
tient. As  a  rule,  in  slight  cases  it  is  possible  to  return  the  foot  gently 
with  the  hands  to  a  correct  position,  when  the  weight  is  not  borne  upon 
it.  In  severe  or  long-standing  cases  it  is  not  generally  practicable  to 
rectify  the  foot  without  the  administration  of  ether  and  the  use  of  con- 
siderable force. 

Tender  points  are  almost  constantly  present  in  marked  flat-foot. 
These  points  are  commonest  over  the  astragalo-scaphoid  articulation  at 
the  inner  border  of  the  foot,  in  front  of  the  internal  malleolus,  and  at 
the  base  of  the  first  and  fifth  metatarsal  bones.  A  less  common  point  is 
to  be  found  in  front  of  the  external  malleolus.     A  tender  point  which 


624:  ORTHOPEDIC   SURGERY. 

may  be  the  source  of  much,  discomfort  is  often  found  under  the  heel  at 
the  anterior  end  of  the  os  calcis.     These  tender  points  may  become  sen- 


Fig.  593.— Tracing  of  a  "  Flat-foot."    No  symptoms, 

sitive  to  pressure  and  to  weight-bearing.     In  acute  cases  there  may  be 
swelling,  localized  heat,  and  redness  of  the  skin. 

The  feet  in  this  condition  are  apt  to  perspire  profusely,  and  a  conges- 


FiG.  594.— Flat-feet  (Imprint). 


tion  is  noticed,  and  in  long-continued  cases  the  thickening  and  vascularity 
of  the  superficial  tissues  may  be  very  marked.     Swelling  of  the  feet  and 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


625 


legs  is  often  an  accompaniment  of  severe  cases  and  may  become  very 
troublesome.  The  gait  is  characteristic  in  a  measure,  as  the  feet  are 
generally  more  everted  than  normal,  and  in  painful  cases  it  will  be  noted 


a  6 

Fig.  595.— a.  Flat-foot ;  b,  flat-foot  with  eversion.    (Children's  Hospital  Report.) 


that  in  standing  the  patient  deliberately  throws  the  foot  over,  so  that  the 

weight  is  borne  more  upon  the  inner  border  than  is  normal.      There  is  a 

lack  of  elasticity  to  the  gait,  and  this  is  a 

symptom  often  complained  of  by  the  more 

intelligent  patients  who  find  their  feet  stiff 

and  clumsy.     After   the  patient  has  been 

sitting  still  for  some  time  and  on  rising  in 

the  morning  the  feet  are  likely  to  feel  stiff 

and  clumsy. 

After  standing  upon  the  feet  for  any 
time,  pain  comes  on  and  becomes  so  severe 
that  it  shoots  up  the  legs,  sometimes  even 
as  far  as  the  thighs.  It  is  somewhat  less- 
ened by  sitting  down,  but  when  once  it  is 
present,  it  is  likely  to  last  for  many  hours. 
It  continues  into  the  night  and  may  be  so 
severe  as  to  prevent  sleep.  The  pain  does 
not  necessarily  correspond  to  the  amount  of 
deformity  present. 

A  wearing  away  of  the  leather  of  the 
boot  over  the  inner  malleoli  in  walking 
may   be   a   symptom   to   attract  attention. 

Other  people  notice  the  prominence  of  the  inner  malleolus,  especially  in 
children,  and  the  abnormal  position  of  the  foot,  before  feeling  pain. 
40 


Fig.  596.— Boot  for  Left  Foot  Worn 
by  Patient  with  Severe  Flat-foot, 
Showing     Characteristic    "  Treading 

Over"  of  Shoe. 


626 


ORTHOPEDIC   SURGERY. 


The  dorsal  flexion  of  the  foot  may  or  may  not  be  limited  at  this  stage 
of  the  affection. 

More  or  less  unusual  symptoms  are  as  follows :  pain  and  a  feeling  of 
strain  at  the  origin  of  the  peroneal  muscles  or  at  the  insertion  of  the 
hamstring,  tendons.  Pain  and  irritability  of  the  knee  and  sometimes  re- 
curring attacks  of  synovitis  of  the  knee.  Backache  must  also  be  men- 
tioned as  an  occasional  symptom  of  flat-foot. 

The  symptoms  here  mentioned  are  also  seen  in  a  weakened  foot,  but 
in  a  less  degree.     There  is  less  stiffness  in  a  weakened  foot  than  in  a 


Fig.  597.— Weakened  Foot. 

flat-foot  with  structural  changes.     The  amount  of  pain,  however,  is  not 
always  in  proportion  to  the  deformity  or  stiffness. 

The  symptoms  may  begin  suddenly  or  gradually.  Sometimes,  when 
it  is  evident  that  flat-foot  must  have  been  present  for  a  long  time,  pain 
and  tenderness  will  suddenly  come  on,  perhaps  spontaneously  or  perhaps 
immediately  after  some  slight  wrench  or  twist  of  the  foot  in  walking. 

Diagnosis. 

The  diagnosis  is  to  be  based  upon  inspection  both  with  and  without 
the  mirror  view  of  the  sole  of  the  foot  and  on  the  record  of  the  foot  trac- 
ing. The  degree  of  flexibility  of  the  foot,  at  the  medio-tarsal  articulation 
is  a  measure  for  distinction  between  a  weakened  and  a  flat-foot. 


Prognosis. 

After  a  time  the  foot  may  become  accustomed  to  its  altered  position 
and  painful  symptoms  cease.  In  other  cases,  however,  the  painful 
symptoms  continue  and  become  worse  rather  than  better  as  years  go  by. 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    027 

The  condition  may  persist  almost  indefinitely,  a  constant  source  of  pain 
and  disability. 

The  results  of  treatment  are  immediate  and  generally  satisfactory. 
In  cases  with  little  permanent  distortion  but  great  muscular  weakness 
benefit  and  cure  can  be  expected  from  careful  treatment.  In  cases  of 
average  severity,  relief  can  almost  always  be  given  by  very  simple 
measures.     A  spontaneous  cure  is  not  to  be  expected. 

Even  after  deformity  of  the  bone  takes  place  and  the  distortion  is 
confirmed,  a  useful  foot  may  be  obtained  if  the  muscular  develop- 
ment of  the  leg  is  good.  A  prominent  "  sprint "  runner  with  a  fine  record 
of  success  showed  on  examination  by  Dr.  D.  A.  Sargent,  of  the  Hemen- 
way  Gymnasium,  well-marked  flat-foot. 

The  prognosis  of  a  valgus  deformity  from  inflammatory  or  paralytic 
causes  varies  necessarily  according  tovthe  nature  and  degree  of  the  origi- 
nal affection. 

Little  need  be  said  of  the  spastic,  paralytic,  traumatic,  or  inflamma- 
tory forms  of  valgus.  The  distortion  resembles  that  of  other  forms,  and 
the  requisite  treatment  is  to  be  conducted  on  the  same  principles  as  are 
needed  for  the  ordinary  varieties  of  flat-foot. 

Treatment. 

The  treatment  of  the  conditions  described  will  depend  upon  the  nature 
of  the  deformity,  its  severity,  and  its  duration. 

The  principles  of  treatment  are  simple  and  consist  of  the  rectification 
of  the  foot  if  distorted,  support  of  the  foot  in  a  proper  position  (if  sup- 
port is  needed),  and  the  development  of  the  strength  of  the  muscles  and 
tissues  until  they  are  sufficient  to  maintain  the  normal  attitude.  These 
measures  are  corrective  and  mechanical. 

Forcible  Correction. — In  cases  in  which  it  is  not  possible  to  place  the 
foot  in  an  approximately  correct  position  on  account  of  stiffness  and  mus- 
cular contraction  it  is  generally  unsatisfactory  to  attempt  the  use  of  a 
support  until  the  position  of  the  foot  has  been  corrected.  Such  patients 
should  be  anaesthetized  and  the  foot  forcibly  twisted  into  shape.  It  must 
be  remembered  that  there  are  two  elements  of  deformity  to  be  corrected : 
first,  eversion  of  the  foot,  and,  second,  abduction  of  the  fore-foot.  This 
can  be  done  manually  in  most  cases,  but  in  severe  cases  such  an  appliance 
as  the  Thomas  club-foot  wrench  will  be  of  use  in  giving  better  leverage. 

The  foot  should  be  over-corrected  if  possible,  or  in  any  event  placed 
in  the  best  obtainable  position  and  held  by  a  plaster  bandage.  It  then 
follows  the  course  of  an  ordinary  sprained  ankle,  generally  of  slight 
degree.  As  soon  as  the  patient  can  walk  without  pain  supports  should 
be  applied. 

In  less  severe  cases  correction  can  be  gradually  accomplished  by  the 
repeated  application  of  plaster-of -Paris  bandages. 


628 


ORTHOPEDIC   SURGERY. 


In  extreme  cases  osteotomy  of  the  neck  of  the  os  calcis  and  astragalus 
may  be  needed,  but  such  cases  are  infrequent. 

Mechanical  treatment  varies  from  the  use  of  appliances  including  the 
leg  to  that  of  supports  for  the  arch  of  the  foot. 

In  the  severer  forms,  especially  when  paralysis  of  certain  of  the 
muscles  is  present,  when  there  is  decided  eversion  of  the  foot,  a  support 
holding  the  leg  is  needed.  Such  may  be  afforded  by  means  of  steel  sole 
plates,  with  an  upright  passing  on  the  outside  of  the  leg,  with  a  support- 
ing strap  around  the  inner  malleolus  described  in  speaking  of  infantile 


^S^ 


Fig.  598.— Valgus  Shoe  for  Paralytic  or  Severe  Cases. 


paralysis.  This  is  the  ordinary  valgus  appliance,  worn  on  the  outside  of 
the  foot  with  a  leather  support  over  the  inner  malleolus  and  secured  to 
the  upright. 

A  form  of  apparatus  has  been  employed  depending  upon  pressure  on 
the  malleolus  by  a  padded  plate  attached  to  uprights  running  up  from 
the  sole  of  the  shoe.  Supports  to  the  arch  of  the  foot  need  to  be  firm 
and  unyielding  in  the  more  severe  forms.  These  are  best  made  of  steel 
shaped  upon  a  cast  of  the  foot.  The  object  of  the  plate  is  to  support 
the  arch  by  pressing  on  the  head  and  neck  of  the  os  calcis,  astragalus, 
the  scaphoid,  and,  in  some  instances,  the  first  metatarsal  upward  and 
outward.  It  is  necessary  that  the  projecting  portions  of  these  bones, 
but  little  covered  by  flesh,   should  not  be  unduly  pressed  upon,   and 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


629 


plates  therefore  vary  according  to  the  individual  and  the  part  of  the 

foot  most  in  need  of  support. 

The  various  shapes  of  plates  that  the  writers  have  found  of  use  are 

shown  in  the  figures.  The  plate  should  fit  the  arch  evenly  and  smoothly 
and  the  pressure  should  be  evenly  distributed. 
Some  outward  thrust  from  the  inner  surface  of  the 
plate  is  needed  over  the  inner  surface  of  the  as- 
tragalus. A  high  inner  edge  in  front  of  this  is  not 
essential. 

The  "  balance "  of   the   plate   is   an   important 
matter.      Either  it  should  rest  securely  in  the  sole 


Fig.  600. -Whitman's 
Flat-foot  Plate.  C,  Great 
toe-joint;  B.  centre  of  the 
heel.    ( Whitman.) 


Fig.  601.— Same.    A,  Astragalo-scaphoid  Joint. 


of  the  boot  or  if  it  tilts  at  all  it  should  be  so  arranged  that  when  weight 
is  borne  upon  it,  it  rolls  the  foot  on  to  its  outer  border  as  in  the  Whit- 
man plate.     A  flange  rising  from  the  plate  at  the  outer  border  of  the 


Fig.  602.— Same.    B,  Calcaneocuboid  Junction. 


foot  is  often  of  assistance  in  keeping  the  foot  from  sliding  off  the  plate 
and,  if  properly  placed,  counteracts  abduction  of  the  fore-foot. 

The  most  useful  material  from  which  to  make  plates  is  tempered 
spring  steel  of  the  requisite  thickness.  It  may  be  protected  from  rust- 
ing by  being  copper-plated  and  then  nickel-plated.     Paint,  japan,  etc., 


630  ORTHOPEDIC   SURGERY. 

as  protectives  are  unsatisfactory  unless  applied  over  nickel.  Hard-rub- 
ber has  been  used  as  a  covering.  Such  steel  plates  are  rigid  except  for  a 
very  slight  elasticity.  Thin  tempered  steel  strips  may  be  embedded  in 
leather  soles,  and  if  properly  shaped,  are  efficient  in  the  milder  cases. 
It  is  not  generally  possible  in  this  way  to  secure  such  accurate  support 
in  irritated  feet  as  by  a  more  rigid  plate. 

Phosphor  bronze  has  been  used  for  foot  plates.     It  is  more  mallea- 
ble and  more  easily  fitted,  but  plates  sufficiently  thick  are  much  heavier 


Fig.  (503.— Photographs  of  Casts  of  Feet  Distorted  by  Improper  Shoes.    (Walsham.) 

than  if  made  of  tempered  steel  and  are  more  inclined  to  yield  under 
weight. 

Aluminum  and  nickel  aluminum  are  light  but  not  sufficiently  rigid 
and  corrode  easily.  Celluloid  has  been  used  with  fairly  satisfactory  re- 
sults. Vulcanized  hard-rubber  makes  a  light  and  comfortable  plate,  but 
it  is  thick  and  breaks  easily. 

To  manufacture  a  plate  a  plaster  cast  is  essential.  This  is  best  taken 
as  follows :  Plaster-of -Paris  and  water  are  mixed  until  a  consistence  is 
obtained  like  that  of  melting  ice-cream.  This  is  poured  into  a  box  or 
oblong  pan,  and  the  patient  sitting  in  a  chair  allows  the  foot  to  rest  on  the 
plaster  without  bearing  weight  on  the  leg.  The  plaster  is  heaped  up  at 
the  inner  border  of  the  foot  to  the  level  of  the  scaphoid.  When  the 
plaster  has  hardened  the  foot  is  withdrawn,  the  mould  painted  with 
shellac,  which  is  allowed  to  dry,  and  the  surface  of  it  is  wiped  with  a 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


631 


greased  rag.     It  is  then  filled  with  plaster  cream.     The  cast  thus  ob- 
tained represents  the  foot  in  a  partially  corrected  position. 

If  the  plate  were  made  to  fit  this  it  would  only  support  the  foot  in  a 
partially  corrected  position.  To  secure  the  pressure  of  the  plate  where 
desired  the  cast  is  then  cut  away  by  a  knife  at  the  points  where  greatest 
pressure  is  wished  and  the  plate  is  fitted  to  the  remodelled  cast. 

In  milder  cases  a  less  rigid  support  can  be  used,  such  as  pads  of  felt. 
Felt  pads  may  be  cut  from  boiler  felt,  reaching  from  in  front  of  the 
heel  to  just  behind  the  head  of  the  first  metatarsal,  highest  at  the  inner 
border  and  sloping  not  only  to  the  outer  border  of  the  foot  but  backward 
and  forward  as  well.  This  may  be  accomplished  by  superimposing  sev- 
eral layers,  each  of  smaller  size  than  the  preceding,  on  each  other.  The 
pad  is  applied  over  the  stocking  and  held  in  place  by  a  turn  of  bandage, 
or  it  may  be  incorporated  in  an  inner  sole  of  leather.  Leather  pads  may 
be  used  in  the  same  way. 

The  Acute  Weakened  Foot. — Certain  cases  are  characterized  by  such 
acute  sensitiveness  that  a  rigid  support  cannot  be  applied;  neither  in 
many  cases  is  the  patient  able  to  rest.  The  support  most  likely  to 
be  tolerated  by  such  patients  is  a  felt 
pad  applied  to  the  bare  foot  over  which 
are  put  strips  of  surgeon's  adhesive 
plaster  in  the  manner  described  by  Gib- 
ney  as  Cottrell's  method  for  use  in 
sprained  ankles.  The  pad  is  put  in  the 
hollow  of  the  foot,  the  foot  held  in  a 
position  of  talipes  varus,  and  strips  of 
one  inch  wide  are  tightly  wound  around 
the  foot  beginning  at  the  outer  border 
passing  under  the  sole  and  up  the  inner 
border  of  the  foot  to  a  point  above  the 
ankle ;  over  this  is  applied  a  snug  cotton 
bandage. 

Boots. — The  boot  may  be  made  cor- 
rective by  being  raised  at  its  inner 
border  by  thickening  the  inner  side  of 
the  sole  and  heel.  This  is  a  modifi- 
cation of  the  method  originally  intro- 
duced by  Thomas  in  the  treatment  of 
flat-foot,  in  which  the  whole  sole  of  the 
shoe  is  raised  along  the  inner  border  by 
means  of  a  wedge.  This  method  is 
often  of  use  in  children,  in  whom  the  sole 

should    be   thickened  from  a   quarter  to  half    an    inch.      The    amount 
necessary  may  be  determined  experimentally  by  blocking  up  the  inner 


FIG.  604.— Boot  for  Valgus  (with 
Short  Leg)  from  Infantile  Paralysis. 
(Galloway.) 


632 


ORTHOPEDIC   SURGERY. 


side  of  the  foot  till  the  correct  position  is  obtained.  In  adults,  with 
notably  too  much  weight  borne  on  the  inner  side  of  the  foot  and  slight 
symptoms,  a  raise  of  from  one-eighth  to  one-quarter  of  an  inch  is 
often  efficient  treatment.  The  objection  to  the  method  is  that  the  foot 
slides  on  the  incline  of  the  sole  and  bears  uncomfortably  hard  on  the 
outer  border  of  the  boot,  sometimes  causing  irritation  over  the  base  of 
the  fifth  metatarsal  and  often  distorting  the  boot  by  stretching  of  the 
leather  over  the  outer  side.  The  less  the  amount  of  raising  the  sole, 
the  less  is  the  likelihood  of  this  objection  to  the  treatment.  The  at- 
tempts to  correct  any  but  the  mildest  grades  of  weakened  foot  by  the 
use  of  corrective  boots  are  generally  unsatisfactory.  Boots  stiffened 
along  the  sides  of  the  ankle  for  the  use  of  children  with  weak  ankles 
so  commonly  sold  are  useless,  and  the  leather  reinforcement  of  the  inner 
side  of  the  boot  for  adults  is  generally  unsatisfactory.  No  matter  how 
much  this  reinforcement  is  stiffened  it  will  naturally  yield,  and  as  a  rule 
affords  only  temporary  support. 

The  use  of  proper  foot  wear  is  sufficient  to  correct  the  mildest  cases, 
and  in  connection  with  proper  hygiene  and  exercises  is  in  these  cases 


a  o  c 

Fig.  605.— a,  Print  on  Smoked  Paper  of  a  Pointed  Shoe ;  b,  imprint  of  foot  wearing  pointed  shoe. 
Doth  indicating  compression  of  the  front  of  the  foot;  c,  print  of  workingman's  shoe,  showing  proper 
room  for  toes. 


sufficient  to  effect  a  cure.  The  adoption  of  proper  foot  wear  is  also 
to  be  regarded  as  a  prophylactic  measure  deserving  consideration.  The 
requirements  of  a  proper  boot  or  shoe  are  to  be  determined  from  what 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


633 


has  been  said  of  the  normal  foot  and  of  the  causation  and  pathology  of 
the  weakened  foot.  Its  object  should  be,  of  course,  to  support  the  foot 
in  an  approximately  correct  position.     It  is  obvious  that  the  great  toe 


Fig.  606.— Children's  Shoes,    a,  Compressing  the  toes;  6  and 
c,  giving  room  for  the  toes. 


Fig.  607.— Modern  Shoe,  Necessa- 
rily Compressing  Toes. 


should  have  room  to  help  support  the  inner  border  of  the  foot ;  that  the 
fore-foot  should  not  be  cramped,  but  should  have  room  to  be  placed  prop- 
erly on  the  ground  in  order  to  perform  its  weight-bearing  function  prop- 


Fig.  608.— Boot  of  Improved 
Pattern.  (Inner  edge  not  so 
straight  as  it  should  be  theo- 
retically.) 


9.— Ordinary  Relation 
of  Boot  to  Foot. 


Fig.  610.- 


-Last  for  Normal  Shoe. 
(Galloway.) 


erly ;    and  that  the  toes  should  be  given  room  and  opportunity  to  touch 
the  ground  in  their  proper  relation  and  thus  be  of  use  in  walking. 

These  requirements  necessitate  that  the  boot  or  shoe  should  have  a 


634 


ORTHOPEDIC   SURGERY. 


straight  inner  line,  that  the  shank  should  be  as  high  as  the  shank  of  the 
individual  foot  when  bearing  slight  weight,  that  it  should  be  fairly  stiff 
and  not  cut  away  at  its  inner  border  any  more  than  is  necessary  for  pur- 
poses of  boot-making.  The  shank  should  be  slightly  higher  at  its  inner 
than  at  its  outer  border.  The  forward  part  of  the  boot  should  be  as  wide 
as  the  weight-bearing  foot  at  that  point,  and  the  toes  should  have  room 
to  be  placed  individually  on  the  ground.  The  forward  part  of  the  sole 
should  not  be  curved  up  as  is  usual, 
but  should  be  flat  to  enable  the 
toes  to  finish  the  step  in  walking; 
neither  should  the  under  surface  of 
the  sole  be  convex  from  side  to 
side,  but  should  set  squarely  on  the 
ground.  The  heel  should  not  be 
unduly  high.     The  forward  part  of 


Fig.  611.— Flat-foot  Boot.    (Galloway.) 


Fig.  612.— Proper  Relation  of  the  Sole  to  the 
Shape  of  the  Foot.  A,  Outline  of  sole ;  2?,  outline 
of  foot ;  C,  imprint  of  foot.    (Whitman.) 


the  boot  should  be  at  somewhat  of  an  angle  to  the  line  of  the  long  axis 
of  the  heel,  that  is,  the  fore-foot  should  be  slightly  adducted  on  the 
posterior  part  of  the  tarsus.  Since  the  position  of  the  weakened  foot  is 
one  of  abduction  of  the  fore-foot,  and  the  position  of  the  foot  under 
muscular  support  is  one  of  adduction  of  the  fore-foot,  it  is  obvious  that 
the  support  of  the  foot  in  the  former  condition  is  corrective  in  character. 
Measures  to  stimulate  the  local  circulation  are  necessary  in  both  the 
weakened  and  in  flat-foot.  Massage  and  electricity  are  of  assistance. 
Douching  alternately  with  hot  and  cold  water  is  a  measure  of  value.     The 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    635 

feet  should  be  soaked  for  five  or  ten  minutes  in  water  as  hot  as  can  be 
borne  and  then  douched  with  cold  water.  The  hot-air  bath  is  also  of 
assistance. 

Gymnastics. — Exercises  to  increase  the  power  of  the  deficient  muscles 
are  sufficient,  in  connection  with  the  measures  already  mentioned,  to  cor- 
rect many  of  the  milder  cases.  They  form  an  important  part  of  the 
treatment  of  all  cases,  mild  or  severe,  whether  or  not  used  in  connection 
with  support  to  the  arch,  and  are  to  be  regarded  as  essential  to  treatment 
of  any  form. 

The  most  notably  deficient  muscles  are  the  tibialis  posticus,  the  flexor 
longus  hallucis,  and  the  short  muscles  of  the  sole  of  the  foot.  Among 
the  exercises  most  commonly  useful  are  the  following.  They  should  of 
course  all  be  taken  without  boots.  The  patient  stands  with  the  feet 
turned  out,  rises  slowly  on  to  the  toes,  turns  out  the  heels,  and  sinks 
slowly  to  the  ground. 

The  patient  walks  with  the  feet  held  in  the  position  of  talipes  varus, 
the  attitude  of  the  feet  being  kept  up  by  strong  muscular  contraction. 

The  patient  learns  to  separate  the  great  toe  from  the  second  toe  later- 
ally and  to  hold  it  in  that  position  while  walking. 

The  patient  learns  to  flex  the  toes  while  the  foot  is  free  and  to  grasp 
objects  in  them  by  their  plantar  surface. 

The  patient  sits  with  the  leg  extended  and  resting  upon  the  assistant' s 
knee.  Forcible  adduction  of  the  fore-foot  is  then  made  while  the  assist- 
ant resists  lightly  with  one  hand  steadying  the  tibia  and  the  other  press- 
ing against  the  ball  of  the  great  toe. 

The  patient  should  be  taught  to  rise  on  the  toes  at  the  end  of  each 
step,  finishing  the  step  with  the  toes. 

Such  exercises  as  the  surgeon  selects  should  be  performed  an  increas- 
ing number  of  times  each  day. 

Morton's  Disease. 
(Metatarsalgia  or  Anterior  Metatarsalgia.) 

This  name  is  used  to  describe  a  cramping  pain  more  or  less  spasmodic, 
situated  between  the  distal  end  of  either  of  the  outer  three  metatarsal 
bones.  It  was  first  described  by  T.  G.  Morton,'  of  Philadelphia,  in 
1876,  and  has  since  that  time  been  studied  by  other  writers.2 

1  Amer.  Journ.  Med.  Sciences,  1876 ;  Phila.  Med.  Times,  October  2d,  1886 ;  Int. 
Med.  Magazine,  1896  and  1897,  v.,  322. 

2 Bradford-  Boston  Med.  and  Surg.  Journal,  cxxv.,  iii.,  52;  T.  S.  K.  Morton: 
Ann.  of  Surg.,  1893,  680 ;  Gibney .  Am.  Journal  Nerv.  aDd  Mental  Dis.,  September, 
1894 ;  Polasson :  Lancet,  March  2d,  1889,  p.  436  ;  Guthrie :  Lancet,  March  19th,  1892, 
p.  628 ;  Woodruff  •  Medical  Record,  January  18th,  1890 ;  Goldthwait :  Boston  Med. 
and  Surg.  Journal,  cxxxi.,  p.  233  ;  Robert  Jones :  Liverpool  Med.  Chir.  Journal,  Jan- 
uary, 1897  ;  Whitman:  Orth.  Trans.,  vol.  xi.,  p.  34. 


636 


ORTHOPEDIC   SURGERY. 


The  condition  is  characterized  by  a  severe  neuralgic  pain,  coming  on 
ordinarily  during  walking,  which  radiates  down  into  the  toes  and  often 
up  into  the  leg.  It  occurs  generally  between  the  third  and  fourth  or 
fourth  and  fifth  toes.  It  may  be  preceded  by  a  sensation  of  slipping  be- 
tween the  ends  of  the  metatarsals,  or  the  slipping  may  occur  without 
the  pain.  It  ordinarily 
comes  on  when  the 
boots  are  on,  but  may 
sometimes  be  occasion- 
ed by  rising  on  the  toes 
in  the  stocking  feet. 
The  patient  seeks  re- 
lief instinctively  by 
removing  the  boot  and 
rubbing  the  foot,  which 
temporarily  relieves  or 
stops  the  pain.  Some 
soreness  may  remain 
afterward  and  a  tender 
spot  is  often  found  at 
the  seat  of  the  pain. 

When  once  estab- 
lished the  attacks  of 
pain  become  gradually 
more  frequent  and 
more  severe.  A  neu- 
ralgic condition  of  the 
leg  and  foot  is  present 
in  severe  cases,  and  the 
patient  learns  to  avoid 
walking.  Spontaneous 
recovery  may  occur, 
but  is  uncommon. 

On  inspection  the 
foot  may  be,  so  far  as 
can  be  ascertained  by 
examination,  perfectly 
normal  in  every  re- 
spect. Oftener,  how- 
ever, one  or  more  of 
the  following  variations  from  the  normal  may  be  detected. 

(1)  The  foot  may  be  weakened  and  of  the  type  described  at  the  head 
of  this  chapter.     Flat-foot  almost  never  coexists. 

(2)  The  anterior  arch  of  the  foot  may  be  relaxed  and  flattened,  the 


Fig.  613.— Radiograph  Showing  Compression  of  Left  Foot  by  Boot. 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    637 


dorsum  of  the  foot  depressed  behind  the  toes,  and  the  front  of  the  foot 
broadened. 

(3)  The  anterior  arch  of  the  foot  may  be  rigidly  held  in  a  depressed 
position. 

(4)  Dorsal  flexion  of  the  foot  may  be  limited  on  manipulation. 

Motion  of  the  toes, 
especially  in  severe 
cases,  is  apt  to  be  lim- 
ited in  the  direction  of 
plantar  flexion. 

The  pain  is  evident- 
ly due  to  some  disturb- 
ance in  the  normal  re- 
lation of  the  anterior 
ends  of  the  metatarsal 
bones.  Morton  thought 
that  it  was  due  to  pinch- 
ing of  the  external  plan- 
tar nerve  between  the 
fourth  and  fifth  meta- 
tarsal bones.  Wood- 
ruff and  Jones  attrib- 
uted it  to  a  direct 
downward  pressure  of 
the  metatarsals  on  the 
digital  nerves  in  the 
sole  of  the  foot.  Jones 
quoted  Tubby  as  find- 
ing one  of  those  nerves 
swollen  and  congested 
on  microscopical  ex- 
amination in  a  case 
operated  upon. 

The   origin  of  the 

condition    is    obscure. 

It    may   be   traumatic 

in  some  cases,  but  it  is 

most    often    obviously 

associated     with     the 

wearing    of    improper 

boots.     Yet  in  some  instances  a  tight  shoe  is  less  uncomfortable  than 

a  loose  one.     It  is  probable  that  compression  of  the  anterior  part  of  the 

foot  by  ill-fitting  boots  is  in  most  cases  the  cause  of  the  affection. 

Although  the  real  condition  is  often  overlooked,  and  a  diagnosis  of 


FIG.  614.— Radiograph  Showing  Right  Foot  Uncompressed  by  Boot. 


638 


ORTHOPEDIC   SURGERY. 


neuralgia  made,  for  which  only  general  treatment  is  prescribed,  yet  the 
diagnostic  symptoms  are  perfectly  well  marked  and  definite  and  not  like 
those  of  any  other  affection. 


Fig.  615.— Meyer's  Line  in  Average  Foot. 


Fig.  616. — Meyer's  Line  in  Normal  Foot. 


The  prognosis  without  treatment  is  not  good,  the  attacks  as  a  rule 
become  more  frequent  and  painful,  though  spontaneous  recovery  does 
rarely  occur.     With  proper  mechanical  treatment  most  cases  recover,  but 


Fig.  617.— Position  of  Hand  in  which  Lateral  Pressure  causes  Pain  at  Metatarsal  Heads.    (Whitman.) 


occasionally  very  obstinate  cases  are  seen  which  resist  all  the  ordinary 
methods  of  treatment. 

Treatment.— -It  is  obvious  that  if  any  static  deformity  of  the  foot  ex- 
ists it  should  be  corrected.  If  the  weakened  foot  is  present  a  proper 
plate  should  be  applied,  brought  well  forward  with  an  elevation  behind 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


639 


the  distal  ends  of  the  metatarsals.  If  the  gastrocnemius  is  short  it 
should  be  stretched.  If  the  anterior  arch  is  relaxed  and  flattened  a  felt 
or  metal  pad  should  be  placed  under  it  behind  the  heads  of  the  metatar- 
sals. In  short,  measures  should  be  adopted  to  relieve  the  front  ends  of 
the  metatarsals  from  pressing  down  on  to  the  sole  of  the  foot  in  finishing 
the  step  in  walking. 

Proper  boots  with  a  broad  sole  should  be  worn,  and  compression  of 
the  front  of  the  foot  by  boots  should  be  avoided.  The  normal  flexibility 
of  the  toes  should  be  cultivated  by  proper  exercises.     In  some  cases, 


Fig.  618.— Normal  Motion  of  the  Front  of  the  Foot. 

however,  compression  of  the  shafts  of  the  metatarsals  for  a  time  affords 
relief.  In  these  cases  it  can  be  afforded  by  adhesive  plaster,  by  bandag- 
ing, or  by  a  boot  made  tight  over  the  shafts  of  the  metatarsals.  Removal 
of  the  distal  end  of  the  fourth  metatarsal  has  been  advocated  as  a  meas- 
ure of  treatment,  but  it  is  not  often  necessary  to  resort  to  this. 


Deformities  of  the  Toes. 

Hallux  Valgus. — This  name  is  applied  to  the  outward  displacement 
of  the  great  toe.  In  the  normal  foot  as  seen  in  children  and  people  who 
do  not  wear  boots  the  long  axis  of  the  great  toe  when  prolonged  backward 
passes  through  the  centre  of  the  heel  (Meyer's  line).     (See  Fig.  603.) 

This  deformity  of  the  great  toe,  however,  is  not  necessarily  the  result 
of  tight  shoes,  for  the  deformity  may  come  in  people  who  have  worn  only 
comparatively  loose  ones.  The  upper  leather  of  shoes  being  more  yield- 
ing than  the  sole,  it  stretches  under  the  pressure  of  use,  or  is  stretched 
to  avoid  pressure  upon  the  metatarso-phalangeal  articulation.  The  boot 
is  not  stretched  at  its  extreme  end,  and  it  inevitably  becomes,  in  a  de- 
gree, conical  in  shape  on  this  account,  being  broader  across  the  ball  of 
the  foot  than  at  the  tip  end.  In  the  act  of  walking  the  foot  necessarily 
slips  inside  of  the  boot  to  a  certain  extent,  and  if  the  shoe  slips  back- 
ward and  the  foot  forward,  a  certain  amount  of  pressure  will  come  upon 
the  inner  side  of  the  end  of  the  great  toe. 

This  deformity  may  also  be  occasioned  by  short  boots,  and  the  ordi- 
nary pointed-toe  boots,  or  any  boot  which  does  not  give  more  room  for 


610  ORTHOPEDIC   SURGERY. 

lateral  spreading  at  the  toes  than  at  the  metatarso-phalangeal  articula- 
tion, would  necessarily  give  rise  to  the  trouble. 

When  the  deformity  continues  for  any  length  of  time,  alteration  of 
the  bones  of  the  metatarso-phalangeal  joiDt  takes  place.  The  head  of 
the  metatarsal  is  partly  uncovered  as  the  phalanx  is  pushed  to  the  outer 
side,  and  the  head  of  the  metatarsal  may  become  enlarged  from  growth 
of  the  bone  due  to  periosteal  irritation.  The  skin  over  this  prominent 
bone  may  grow  thick  and  a  bursa  form  on  the  outer  edge.  This  may  be- 
come inflamed,  giving  rise  to  an  extensive  cellulitis,  which  may  include 
the  whole  dorsum  of  the  foot,  which  may  suppurate  and  cause  necrosis  of 
the  bone.  This  latter  termination  is,  however,  rare  and  occurs  only  in 
neglected  cases. 

The  symptoms  due  to  hallux  valgus  in  the  non-inflammatory  stages 
are  chiefly  those  resulting  from  the  alteration  of  the  shape  of  the  foot. 
In  aggravated  cases  a  peculiar  gait  is  noticeable,  the  foot  is  thrown  out 
and  there  is  loss  of  elasticity  in  the  gait.  There  may  be  pain,  and  in 
the  severe  cases  extreme  pain  and  difficulty  in  walking,  which  is  usually 
attributed  by  the  patient  to  gout.  It  is  almost  exclusively  an  affection 
of  adult  life,  but  is  occasionally  seen  in  adolescence.  In  old  age  it  is 
often  found  in  conjunction  with  chronic  rheumatoid  arthritis,  or  with 
bunion.  On  examination  sensitiveness  of  the  metatarso-phalangeal  joint 
is  detected  on  pressure. 

Treatment. — The  treatment  of  hallux  valgus  in  children  is  best  carried 
out  by  wearing  a  splint  of  steel  or  hard-rubber  along  the  inner  border  of 
the  foot  fastened  behind  to  the  metatarsus.  To  the  front  end  of  this 
splint  the  toe  is  bandaged  or  strapped  and  thus  pulled  outward. 

The  use  of  a  toe  post  is  sometimes  beneficial.  That  is,  a  metal  parti- 
tion is  attached  to  the  sole  of  the  boot,  which  shall  come  between  the 
first  and  second  toes  and  hold  the  great  toe  in  an  improved  position.  For 
the  use  of  this  toe  post  a  stocking  is  required  which  shall  have  a  division 
between  the  great  toe  and  the  other  toes. 

The  use  of  a  foot  plate  curved  to  support  the  arch  of  the  foot  may  be 
of  use  when  the  foot  is  weakened  or  flat. 

Shoes  should  be  so  constructed  that  no  pressure  is  possible  which  will 
force  the  great  toe  to  the  outer  side.  The  sole  of  the  shoe  should  be  not 
only  as  broad  as  the  sole  of  the  foot,  but  in  cases  in  which  there  is  a  ten- 
dency to  this  deformity,  there  should  be  room  made  in  the  front  of  the 
shoe  for  the  first  metatarso-phalangeal  joint  of  the  large  toe  to  move  to 
the  inside. 

In  old  cases  attempts  to  correct  the  deformity  by  such  means  as  those 
mentioned  are  generally  unsuccessful  and  operative  measures  may  be 
adopted. 

The  joint  may  be  resected  through  an  incision  along  the  inner  ami 
upper  surface  of  the  joint,  the  section  of  the  bones  being  made  in  such 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET.    641 

planes  that  the  cut  ends  of  the  bones  when  in  apposition  keep  the  toe 
in  its  proper  position.  A  wedge-shaped  osteotomy  of  the  first  metatarsal 
behind  the  joint  will  correct  the  deformity  in  many  cases  and  has  the 
advantage  of  not  destroying  the  joint  surfaces. 

Resection  of  the  joint  may  be  performed  through  an  incision  made 
between  the  first  and  second  toes.  By  this  method  the  cicatrix  is  not 
subjected  to  the  friction  of  the  boot.  The  use  of  properly  made  shoes  is 
essential  for  after-treatment,  and  also  for  the  prevention  of  the  increase 
or  recurrence  of  the  deformity. 

Bunion  is  the  name  applied  to  an  inflammation  of  a  bursa  which 
forms  on  the  inside  of  the  metatarso-phalangeal  articulation,  and  in  some 
eases  to  an  inflammation  of  that  joint  itself.  It  occurs  most  often  in 
connection  with  hallux  valgus.  ( 

Hallux  Varus. — This  deformity  is  not  a  common  one,  and  is  known 
also  as  in-toe  or  pigeon  toe.  It  is  rarely  of  any  importance,  and  although 
often  congenital  in  origin,  it  may  occasionally  be  seen  in  young  children 
with  flat-foot,  and  the  writers  have  observed  it  in  a  few  cases  of  over- 
corrected  club-foot  in  which  a  valgus  has  resulted.  It  is  also  seen  in 
connection  with  severe  knock-knee  at  times. 

This  distortion  does  not  generally  require  treatment,  and  the  use  of 
ordinary  shoes  is  sufficient  to  correct  the  deformity. 

Hallux  Rigidus. — This  deformity  is  sometimes  seen  in  adolescents, 
consisting  of  an  ankylosis  at  the  metatarso-phalangeal  joint  of  the  great 
toe.  The  deformity  consists  of  a  forced  flexion  of  the  proximal  phalanx 
of  the  great  toe  through  30°  to  60°,  with  extension  of  the  second  phalanx. 

The  symptoms  vary  with  the  stage  of  the  disease.  Early  there  may 
be  slight  pain  over  the  joint  and  painful  motion,  but  the  cases  rarely  come 
to  the  surgeon's  notice  at  this  time.  Later  there  is  swelling  over  the  joint, 
with  rawness  and  tenderness,  and  perhaps  an  enlargement  of  the  bone 
itself.  If  the  disease  progresses,  the  joint  becomes  ankylosed  in  the 
distorted  position  and  the  fascia  and  muscles  contract  and  still  more 
firmly  secure  the  deformity  in  position.  The  usual  atrophy  after  anky- 
losis often  occurs  here. 

The  condition  is  often  associated  with  flat-foot.  Ill-fitting  shoes  also 
have  an  influence  in  causing  the  distortion.  At  times  it  arises  from  an 
injury. 

The  treatment  in  the  early  stages  will  consist  in  removing  the  ex- 
citing cause,  and  properly  supporting  the  foot.  If  there  is  pain,  with 
signs  of  inflammation,  rest  with  local  applications  is  indicated,  and  later 
protection  by  splints  with  support  of  the  arch  of  the  foot.  In  inveterate 
cases  excision  of  the  joint  may  be  necessary. 

Hammer  Toe. — This  deformity  consists  of  a  claw-like  contraction  of 
one  of  the  toes,  usually  the  second  or  third.  The  condition  is  one  of 
flexion  of  the  second  phalanx,  with  extension  of  the  third,  so  that  the 
41 


642  ORTHOPEDIC   SURGERY. 

pressure  on  the  ground  is  sustained  by  the  distal  phalanx.  Over  the 
upward  projecting  joint  there  is  usually  a  callosity,  which  may  cause  con- 
siderable annoyance. 

The  origin  of  the  deformity  is  not  well  understood,  but  in  some  cases 
it  is  apparently  caused  by  short  boots. 

In  the  slight  degrees  and  early  stages  of  the  deformity,  the  patient 
experiences  but  little  discomfort,  and  such  cases  are  not,  therefore,  coni- 


Fig.  619.— Hammer  Toe. 

monly  seen  by  the  surgeon  in  this  stage.  Later,  however,  locomotion 
becomes  difficult  and  painful. 

In  children  and  adolescents  the  deformity  can  generally  in  all  but  the 
severest  cases  be  corrected  by  simple  mechanical  treatment.  The  toe 
should  be  bandaged  or  strapped  to  a  rigid  plantar  splint,  which  can  easily 
be  made  of  tin.  The  strapping  should  be  renewed  often  enough  to  keep 
the  toe  extended.  In  very  severe  cases  and  in  adults  the  deformity  is 
best  remedied  by  amputation  at  the  metatarso-phalangeal  articulation. 
In  children  it  can  be  corrected  if  necessary  by  subcutaneous  section  of  the 
contracted  fasciae,  forcible  straightening,  and  fixation  in  a  straight  posi- 
tion by  means  of  splints  and  adhesive  plaster. 

Amputation  at  the  interphalangeal  joint  is  of  no  use,  as  the  proximal 
phalanx  remains  still  elevated,  so  that  the  only  operative  procedure 
worthy  of  consideration  is  amputation  at  the  metatarso-phalangeal  artic- 
ulation. After  correction  by  mechanical  means  the  deformity  shows  a 
tendency  to  recontract  and  must  be  carefully  watched. 

Other  operations  than  amputation  have  been  recently  advocated  for 
the  relief  of  this  condition.  Adams  divides  the  external  lateral  liga- 
ments subcutaneously,  and  extending  the  toe  keeps  it  on  a  metal  splint 
for  three  or  four  weeks.  Petersen  removes  the  soft  and  tendinous  struc- 
tures from  the  under  side  of  the  affected  toe.  Terrier  makes  a  longi- 
tudinal incision  along  the  dorsum  of  the  toe  and  removes  with  bone  for- 
ceps the  ends  of  the  phalanges  which  form  the  affected  joint,  and  then 
cutting  away  the  bursa  and  the  callus  from  the  top  the  toe  is  dressed  in 
the  extended  position.  Cuneiform  osteotomy  has  been  done  with  per- 
fectly satisfactory  results. 

Deviation  of  the  Small  Toes. — The  other  toes  may  be  displaced  from 
being  crowded  together,  either  in  such  a  way  that  one  toe  is  forced  to 
lie  upon  or  over  the  others.  This  is  almost  invariably  an  acquired  affec- 
tion, but  may  rarely  be  seen  in  the  feet  of  infants.      This  crowding  may 


FLAT-FOOT  AND  OTHER  AFFECTIONS  OF  THE  FEET. 


643 


also  cause  the  toe  to  double  on  itself  in  such  a  way  that  the  head  touches 
the  ground  at  the  end  of  the  nail,  instead  of  on  the  pulp.  This  forced 
flexion  may  become  so  severe  as  to  give  much  annoyance,  causing  an 
ulceration  at  the  end  of  the  toe  and  an  inflamed  bursa  on  the  dorsum. 
This  position  of  the  toes  may  also  be  the  result  of  unequal  power  of  the 
antagonistic  muscles. 

In  children  and  in  light  cases,  the  deformity  may  often  be  corrected 
by  replacing  the  toe  and  securing  it  in  position  by  winding  adhesive 


Fig.  630.— Bony  Spurs  on  Upper  and  Lower  Surfaces  of  Os  Calcis.     (Painter.) 


piaster  about  it  and  a  contiguous  toe,  which  may  serve  as  a  splint,  and 
by  attention  to  proper  shoes. 

In  adults  and  in  pronounced  cases,  amputation  is  the  only  satisfactory 
method  of  treatment. 

A  contracted  position  of  several  toes  is  sometimes  seen,  either  as  a  re- 
sult of  improper  shoeing  or  as  a  sequel  to  a  previous  paralysis  of  some  of 
the  muscles  of  the  foot.  It  also  occurs  at  times  in  connection  with  what 
has  been  spoken  of  as  contracted  foot.  The  tendons  and  fasciae  will  be 
found  shortened. 

This  deformity  is  to  be  treated  in  the  same  way  as  the  contraction  of 
one  toe.  In  this,  as  in  all  similar  affections  of  the  toes,  properly  mad? 
shoes  are  necessary  to  prevent  relapse  or  to  secure  permanent  recovery. 

It  is  safe  to  say  that,  in  obstinate  cases,  all  contracted  fasciae  or  ten 
dons  should  be  freely  divided. 


644 


ORTHOPEDIC    SURGERY. 


The  various  joints  of  the  toes  may  become  inflamed,  and  ankylosis 
of  the  metatarso-phalaugeal  articulation  may  occur;  for  the  former, 
Thomas'  shoe,  which  keeps  the  toe  at  rest,  is  of  use.  It  has  been  de- 
scribed in  speaking  of  the  diseases  of  the  ankle-  and  foot-joints. 

Tuberculosis  of  the  diaphyses  of  the  metatarsals  occurs  at  times  in 
children. 

Miscellaneous  Conditions. 

Painful  Heel. — A  condition  is  occasionally  seen  in  which  severe  pain 
and  tenderness  are  present  in  the  heel  at  the  posterior  attachment  of  the 
plantar  fascia.     This  has  been  spoken  of  as  "policeman's  heel."     The 


Fig.  621.— A  Bony  Thickening  on  Upper  Surface  of  Os  Calcis,  which  was  Removed.    (Painter.) 


etiology  of  the  affection  is  obscure,  in  some  cases  it  is  accompanied  by 
exostoses  of  the  os  calcis. 

Exostoses  of  the  tarsal  bones,  especially  of  the  os  calcis,  are  found 
from  time  to  time  accompanying  a  painful  and  even  a  disabling  condition 
of  the  foot.  Inflammation  of  the  post-calcaneal  bursa  has  been  described 
in  connection  with  this  condition.1  The  exostoses  are  found  by  skia- 
graphs. 

The  etiology  is  obscure.  In  some  cases  gonorrhoea  may  have  preceded 
it,  while  in  others  there  is  no  evidence  of  it.  The  affection  is  obstinate 
and  recovery  slow.  It  is  not,  as  a  rule,  much  benefited  by  treatment,  and 
the  removal  of  the  exostoses  has  not  regularly  been  followed  by  relief  and 
should  not  be  undertaken  in  the  very  acute  stage. 

'Painter:  Orth.  Trans.,  vol.  xi.  (with  bibliography). 


FLAT-FOOT   AND   OTHER   AFFECTIONS   OF   THE   FEET.  645 

Rest,  dry  heat,  fomentations,  douching,  massage,  etc.,  all  have  their 
place  in  improving  certain  cases.  Partial  relief  is  often  to  be  obtained 
by  the  use  of  a  support  to  the  arch  of  the  foot,  relieving  the  heel  from 
some  of  its  pressure. 

Nodules  in  the  plantar  fascia  are  occasionally  found  in  connection  with 
arthritis  deformans. 

Pied  Force. — A  painful  condition  of  the  foot  known  as  pied  force  has 
been  mentioned  by  French  surgeons  as  occurring  generally  among  soldiers 
who  are  obliged  to  take  prolonged  marches.  A  swelling  on  the  dorsum 
of  the  foot  occurs,  accompanied  by  pain  and  functional  disability.  This 
condition  is  followed  often  by  exostoses,  oftenest  on  the  second  metatarsal 
bone.  It  was  formerly  thought  to  be  due  to  a  periostitis  or  synovitis, 
but  investigations1  by  means  of  skiagraphs  have  shown  a  bony  deformity 
of  the  metatarsals  resembling  that  which  follows  fractures. 

1  Boisson  and  Chapotot:  Arch,  de  Mdd.  et  de  Pharmacie  Militaire,  February,  1899. 


GENERAL    INDEX. 


Abscess  in  hip  disease,  219 
in  joint  disease,  177 
in  Pott's  disease,  6,  34 
periarticular,  173,  202 
Acetabular  hip  disease,  205 
Acromio-clavicular  joint,  disease  of,  379 
Age  and  joint  disease,  182 
Amputation  for  knee-joint  disease,  334 

of  the  hip-joint,  291 
Ankle,  congenital  dislocation  of,  448 
diseases  of,  353 
excision  of,  359 
functional  affections  of,  357 
hysterical  disease  of,  521 
osteoplastic  resection  of,  360 
results  of  treatment,  358 
splints  for,  358,  362 
synovitis  of,  353 
tuberculous  disease  of,  354 
treatment  of,  357 
Ankylosis,  203 

and  immobilization,  262 
Apophysalgie  pottique,  18 
Apparent  shortening  in  hip  disease,  220 
Aran-Duchenne  type  of  muscular  atrophy, 

512 
Arthrectomy  of  elbow,  373 

of  knee,  333 
Arthritis,  acute,  of  hip,  299 
acute,  of  infants,  185 
ankylopoietica,  168 
Arthritis  deformans,  190 
bacteriology,  192 
in  children,  193 
of  hip,  297 
of  knee,  339 
pathology,  191 
of  spine,  148 
of  wrist,  373 
Arthritis,  gonorrhoeal,  196 
'in  infectious  diseases,  194 
in  scarlet  fever.  194 
in  syphilis,  189 


Arthritis  in  typhoid,  194 

of  infants,  185 

pauper  um,  194 

rheurnatica  ankylopoietica,  193 
Arthrodesis  in  infantile  paralysis,  486 
Aspiration  of  cold  abscesses,  72 
Athetosis,  491 

Atrophy  in  hip  disease,  215,  231,  240 
Attitude  in  hip  disease,  212 

in  Pott's  disease,  31 

in  psoas  contraction,  33 

of  rest,  551 

Bed  frame  for  hip  disease,  256 
frame  for  Pott's  disease,  42 
Beely's  club-foot  appliance,  392 

corset,  130 
Bleeder's  joints,  200 
Boots,  631 
Bow  legs,  565 
anterior,  576 
etiology,  565 
expectant  treatment,  570 
mechanical  treatment,  571 
osteoclasis,  574 
osteotomy,  576 
prognosis,  569,  577 
Brisement  force"  in  hip  disease,  276 
Buckminster  Brown's  splint  for  torticol- 
lis, 588 
Bunion,  641 

Bursa,  post-calcaneal,  644 
Bursitis,  204 
of  hip,  301 
of  knee,  341 

Cabot's  hip  splint,  261 

Calot's  reduction  in  Pott's  disease,  45 

Carcinoma  of  bone,  188 

Caries  of  spine,  1 

Casts  for  flat-foot  plates,  630 

Cerebellar  type  of  hereditary  ataxia,  515 

Cerebral  paralysis,  488 


648 


GENERAL   INDEX. 


Cerebral  paralysis,  apparatus  in,  503 

atrophy  in,  490 

contractures  in,  490 

diagnosis,  499 

epilepsy  in,  501 

etiology,  494 

mental  defects  in,  489 

mobile  spasm  in,  491 

operative  treatment,  503 

pathology,  495 

prognosis,  500 

spastic  condition  in,  492 

treatment,  501 
Cerebro-spinal      meningitis,      paralysis 

from,  467 
Charcot's  disease  of  the  hip,  299 

joint  disease,  198 
Chest,  deformities  of,  164,  536 

deformities  in  Pott's  disease,  11,  22 
Chondrodystrophia  fcetalis,  529 
Chondroma,  187 
Club-foot,  380 

anatomy,  380 

Beely's  appliance,  392 

bone  operations  in,  402 

causation,  383 

diagnosis,  388 

forcible  correction  of,  413 

in  hereditary  ataxia,  514 

mechanical  correction,  391 

osteotomy,  407 

paralytic,  423,  461,  481 

Phelps'  operation  for,  400 

plantar  fascia,  division  of,  396 

prognosis,  389 

relapses  in,  418 

resection  of  bones  for,  404 

results  of  treatment,  421 

retentive  appliances,  419 

splints,  414 

symptoms,  387 

Taylor  shoe,  418 

tenotomy,  395 

treatment,  389 

varus  shoe,  418 
Club-foot,  non-deforming,  600 
Club-hand,  424 
Congenital  dislocation  of  ankle,  448 

of  elbow,  447 

of  hip,  427 

of  knee,  447 

of  shoulder,  446 

of  wrist,  447 


Congenital  elevation  of  scapula,  593 
Congenital  talipes  valgus,  616 
Congenital  torticollis,  579 
Contracted  foot,  600 
Convalescent  splint  for  hip  disease,  271 

splint  for  tumor  albus,  322 
Coxa  vara,  302 
Craniotabes,  535 
Cysts  of  knee-joint,  340 

Deformities  in  infantile  paralysis,  459 
Dislocation  of  hip  (paralytic),  464 

of  semilunar  cartilages  of  knee,  345 
of  shoulder  (habitual),  368 
Distribution  of  tuberculous  joint  disease, 
184 

Elbow,  arthrectomy,  373 

congenital  dislocation,  447 

excision,  372 

synovitis,  370 

tuberculous  disease,  370 
Encephalitis,  49 

Epilepsy  in  cerebral  paralysis,  501 
Epiphyseal  hypersemia,  203 
Epiphyses  in  rickets,  535 
Epiphysitis,  acute,  186 
Etiology  of    tuberculous  joint  disease, 

180 
Excision  in  paralytic  knock-knee,  565 
Excision  of  ankle,  359 

of  elbow,  372 

of  hip,  280 

of  knee,  328 

of  shoulder,  367 

of  wrist,  374 
Exercises  in  lateral  curvature,  125 
Exostoses,  187 

of  tarsal  bones,  644 
Experimental  causation  of  lateral  curva- 
ture, 97 
Experiments  on  value  of  traction,  248 

Faulty  attitudes,  103,  142 

Feet,  examination  of,  608,  623 

Fingers,  diseases  of,  378 

Fixation  of  joints,  results  of,  203,  262 

treatment  of  hip  disease,  259 
Flat-foot,  605 

anatomy,  617 

etiology,  621 

forcible  correction  of,  627 

plates  in,  628 


GENERAL   INDEX. 


649 


Flat-foot,  symptoms,  622 

tender  points  in,  623 

treatment,  627 
Flexion  of  knee  in  tumor  albus,  322 
Foot,  anatomy  of  bones  of,  611 

in  infancy,  606 

pronation  of,  609 

the  weakened,  607 
Forcible  correction  in  Pott's  disease,  45 

straightening  of  joints,  486 

straightening  of  knee,  323,  325 
Fracture  of  hip  in  children,  306 

in  hip  disease,  207 
Friedreich's  disease,  513 
Functional  affections  of  joints,  517 

affections  of  spine,  161 
Funnel  chest,  164,  536 

Gant's  osteotomy  of  the  hip,  276 

Genuclast,  327 

Genu  recurvatum,  447 

valgum,  546 

varum,  565 
Gout,  194 

Gouttiere  de  Bonnet,  262 
Growing  pains,  203 
Gummatous  ostitis,  189 

Hemophilia,  joint  disease  in,  199 
Hallux  rigidus,  641 
valgus,  639 
varus,  641 
Hammer  toe,  642 
Harrison's  sulcus,  163,  164 
Heel,  painful,  644 
Hemiplegia,  488 
Heredity  in  tuberculous  joint  disease, 

180 
Hey's    internal    derangement    of    knee 

joint,  345 
Hip,  congenital  dislocation  of,  427 

diagnosis,  434 

differential  diagnosis,  437 

etiology,  430 

forcible  reposition,  442 

frequency,  427 

operative  reduction,  439 

pathology,  431 

prognosis,  438 

results  of  operation,  446 

sex  in,  429 

symptoms,  434 

treatment,  439 


Hip,  congenital  dislocation  of,  varieties 

l:;l 
Hip  disease,  205 

abscess  in,  210,  219 

treatment  of,  273 
abduction,  228 
acetabular,  205 
adduction,  228 
amputation  for,  292 
atrophy,  215,  231 
attitudes  in,  212,  226 
bed-frame  in,  256 
brisement  force,  276 
Cabot  splint,  261 
causes  of  death,  235 
convalescent  splint,  270 
deformities,  217 

treatment  of,  275 
diagnosis,  223 
differential  diagnosis,  231 
dislocation  in,  207 
double,  222,  279 
duration  of  treatment,  239 
examination  in,  223 
excision,  280 

results  of,  284 
flexion,  229 

forcible  straightening,  276 
general  condition  in,  221 
incision  of  joint,  291 
lateral  traction,  256 
limp,  212,  213 
long  traction  splint,  263 
measurement  in,  226 
mortality,  234 
muscular  fixation,  215,  223 
night  cries,  214,  274 
osteotomy,  276 
pain,  213,  231 
pathology,  205 
plaster  bandage,  257 
prognosis,  233,  234 

of  atrophy,  240 
relapses,  272 
remissions,  221 
results  of  treatment,  238.  241 
separation  of  epiphysis,  207 
sequestra,  209 
short  traction  splint,  269 
shortening,  220,  227,  279 
swelling,  231 
symptoms,  211 
temperature,  222 


650 


GENERAL   INDEX. 


Hip  disease,  Thomas  splint,  259 

traction,  248 

results  of,  254 

traction  splints,  2G3 

treatment,  248 

trephining  trochanter,  291 
Housemaid's  knee,  841 
Hydrocephalus  and  rickets,  536 
Hydrops  articulorum  tuberculosus,  176 
Hypersesthetic  spine,  36,  161 
Hypertrophy,  unilateral,  595 
Hysterical  hip,  520 

joints,  517,  523 

knee,  521 

spine,  36,  161 

Idiocy,  493 

Immobilization  and  ankylosis,  262 
Incision  of  joint  in  hip  disease,  291 
Infantile  paralysis,  450 

arthrodesis  in,  486 

Burrell's  splint,  478 

club-foot  in,  461 

contracted  knee  in,  480 

deformities  in,  459,  479 

diagnosis,  465 

differential  diagnosis,  466 

dislocations  in,  463 

distribution  of  paralysis,  457 

electrical  reaction  in,  465 

epidemic,  452 

etiology,  450 

hip  deformity  in,  479 

knock-knee  in,  460 

mechanical  treatment,  473 

pathology,  452 

prognosis,  468 

splints,  474 

symptoms,  455 

talipes  calcaneus  in,  462 
valgus  in,  461 

tendon  transplantation  in,  481 

treatment  of,  469 

of  deformities  in,  486 
Intermittent  hydrops,  167 
Internal  derangement  of  the  knee-joint, 

345 
Ischias  scoliotica,  94 

Jaw,  arthritis  of,  379 
Joint  affections  in  gout,  194 

gonorrhoea,  196 

hgemophilia,  200 


Joint  affections   in  infectious  diseases, 
194 

Pott's  disease,  24 

pulmonary      hypertrophic     osteoar- 
thropathy, 200 

scarlet  fever,  194 

scurvy,  199 

syphilis,  189 

tabes  dorsalis,  198 

typhoid,  194 
Joint  "mice,"  201 
Joints,  functional  affections  of,  517 

tumors  of,  187 
Jury-mast,  58 

Knee,  arthritis  deformans,  339 

bursitis,  341 

congenital  dislocation,  447 

cysts,  340 

housemaid's,  341 

hysterical,  521 

internal  derangement,  345 

loose  bodies  in,  343 

semilunar  cartilages,  345 

synovitis,  337 

trigger,  352 

tuberculosis,  308 
Knee,  tumor  albus,  308 

abscesses,  328 

amputation,  334 

ankylosis,  332 

arthrectomy,  333 

convalescent  splint,  321 

deformity  in,  313 
treatment  of,  323 

diagnosis,  316 

dislocation  in,  314 

excision,  328 

erosion,  333 

fixation,  317 

forcible  straightening,  323 

genuclast,  327 

limp  in,  312 

osteotomy  in,  333 

pain,  312 

pathology,  308 

prognosis,  317 

protective  splint,  321 

rotation  tibia,  315 

sequestra,  309 

shortening,  311 

spasm,  313 

subluxation  in,  314 


GENERAL   INDEX. 


051 


Knee,  tumor  albus,  Thomas  knee  splint, 
319 

traction  in,  325 

treatment,  317 
Knock-knee,  545 

condyles,  552 

etiology,  548 

excision  in  paralytic,  565 

expectant  treatment,  555 

frequency,  546 

gait  in,  552 

Macewen's  osteotomy  for,  561 

manipulation  in  the  treatment,  556 

mechanical  treatment,  557 

mechanics,  548 

Ogston's  operation  for,  561,  563 

osteoclasis  for,  564 

osteotomy  for,  560 

paralytic,  555 

pathology,  550 

prognosis,  555 

splints  for,  557 

tracings,  554 
Kyphosis,  142 

in  Pott's  Disease,  1 

in  paralysis,  146 

in  rickets,  145 

of  occupation,  143 

of  old  age,  143 

Laminectomy,  74 
Lateral  curvature,  79 

caries  and,  113 

cervical,  85 

chest  in,  109 

classification  of,  85 

congenital,  79 

contraction  of  chest  in,  92 

distortion  of  vertebrae,  106 

dorsal,  86 

etiology,  94,  102 

examination,  111 

exercises  in,  125,  131 

fixed  curves  in,  81 

frequency  of,  79 

general  condition  in,  83 

in  ischias  scoliotica,  94 

intermittent  correction  in,  133 

jackets,  129,  131 

kyphosis  in,  91 

limp  in,  88 

lumbar,  87 

mechanism,  96,  101 


Lateral  curvature,   mechanism  of    rota- 
tion, 107 

methods  of  recording,  114 

muscles  in,  80,  81,  110 

neurasthenic  symptoms,  82,  83 

pain,  82 

paralytic,  92 

pathology,  104 

physiological  curves,  94 

pressure  correction  in,  132 
by  jackets,  134 

prevention  of,  118 

prognosis,  115 

rhachitic,  90 

static,  91 

treatment  of,  122 

choice  of  methods,  138 

varieties  of,  84,  90 

vertebrae  in,  108 
Lateral  deviation  in  Pott's  disease,  15,  17 
Lipoma  arborescens,  201 
Little's  disease,  488 
Loose  bodies  in  knee-joint,  343 

bodies  in  joints,  201 

bodies  in  the  hip-joint,  301 
Lordosis,  146 

in  rickets,  535,  537 
Lumbar  abscess,  26 

Macewen's   osteotomy   for  knock-knee, 
561 

Malignant  disease  of  hip,  53,  299 
disease  of  spine,  153 

Malpositions  of  limb  in  hip  disease,  217 

Mechanism  of  malpositions  of  foot,  615 

Meningitis  in  Pott's  paraplegia,  7,  10 

Mental  impairment  in  cerebral  paralysis, 
489 

Metatarsalgia,  635 

Metatarso-phalangeal  articulations,  dis- 
ease of,  362 

Morbus  coxae  senilis,  297 

Morton's  disease,  635 

Muscular  spasm  in  hip  disease,  215 

Neuromimesis — see  Functional  affections 

of  joints 
Neuropathic  arthropathy,  198 
Night  cries,  214 
Non-deforming  club-foot,  600 

Obstetrical  paralysis,  515 
Ocular  torticollis,  581 


652 


GENERAL   INDEX. 


CEdema  of  spinal  cord,  8 

Ogston's  operation  for  knock-knee,  561, 

563 
Osteochondritis,  189 
Osteoclasis  for  knock-knee,  564 

in  bow-legs,  574 
Osteoclast  of  Rizzoli,  574 
Osteomalacia,  144,  544 
Osteomyelitis,  acute,  185 

of  spine,  151 
Osteotomy  for  bow-legs,  576 

for  club-foot,  407 

for  deformity  at  hip,  276 

for  deformity  at  knee,  332 

for  infantile  paralysis,  486 

for  knock-knee,  560 
Ostitis,  187 

deformans,  144 

of  spine,  6 

Paci's  reduction  in  congenital  disloca- 
tion of  hip,  442 
Paget's  disease,  144 
Painful  affection  of  foot  (Morton's),  635 

heel,  644 
Paralysis,  cerebral,  488 

infantile,  450 

in  Pott's  disease,  23 
pathology,  6 
treatment,  74 

in  rickets,  533 

pseudo-hypertrophic,  507 
Paralytic  club-foot,  423,  461,  481 

spinal  curvature,  92 

valgus,  461 
Paraplegia  dolorosa,  155 
Parrot's  disease,  189 
Patella,  dislocation  of,  348 
operation  for,  351 
Patellar  ligament,  elongation  of,  351 

tendon,  rupture  of,  352 
Periarticular  abscess,  173 
Perineal  bands,  266 
Pes  arcuatus,  603 

cavus,  603 

valgus,  616 
Phelps'  operation  in  club-foot,  400 
Physiological  curves  of  spine,  94,  141 
Pied  force,  645 

Pigeon  breast,  23,  162,  164,  536 
Plantar  fascia,  division  of,  396 
Plaster  jackets,  52 
Plaster  in  flat-foot,  628 


Poliencephalitis,  497 
Poliomyelitis  anterior,  450 
Porencephalus,  495 
Posterior  torticollis,  590 
Pott's  disease,  1 

abscess,  treatment,  79 
apparatus  for  correction,  49 
attitudes  in,  13,  31,  33 
Calot's  reduction,  45 
care  of  skin  in,  43 
causation,  12 
causes  of  abscess,  25 

of  death  in,  38 

of  paralysis  in,  7,  10 
celluloid  jackets, 
cervical,  31 

abscess,  28 
chest  in,  11,  22 
compensatory  curves,  21 
course,  28 
deformity,  19,  40 

of  chest,  11,  22 
diagnosis,  29 

of  abscess  in,  34 

of  paralysis  in,  35 
dorsal,  33 
examination,  30 
eye  symptoms,  19 
forcible  correction,  45 

correction,  repair  after,  47 
gait,  31,  33 
general  condition,  23 
Goldthwait's  head  support,  67 
graduated  correction,  49 
growth  in,  21,  40 
head  supports  in,  67 
head-traction  in,  43 
heart  and  vessels,  11 
incision  of  abscess  in,  72 
indications  for  treatment,  59,  68,  78 
joints  in,  24 
jury-masts  for,  58 
laminectomy,  74 
lateral  deviation,  15,  17 
leather  jackets,  57 
leucocytosis,  29 
localization  of,  12 
lumbar  abscess,  27 
meningitis,  7,  10 
mortality,  38 
oedema  of  cord,  8 
ostitis,  superficial,  in,  6 
pain  in,  18 


GENERAL   INDEX. 


653 


Pott's  disease,  paper  jackets,  57 

paralysis,  23 

pathology,  1 

pathology  of  abscess,  6 
of  paralysis,  6 

pigeon  breast,  23 

plaster  jackets,  54 

prognosis,  37,  75 
of  paralysis,  76 

psoas  abscess,  20 

contraction,  15,  17,  29,  33 
-contraction,  treatment  of,  73 

recumbency,  41,  44 

relation  of  paralysis  to  deformity,  7 

repair,  11,  47 

results  of  forcible  correction,  40 

retropharyngeal  abscess,  25,  28 

rigidity,  16,  30 

secondary  curves,  21 

spontaneous  cure,  21 

suspension  in,  52 

symptoms,  13 

Taylor  brace,  59 

Taylor  head  support,  66 

temperature  in,  23 

Thomas'  collar,  67 

traction  in,  43 

treatment,  40 

of  paralysis  in,  74 

wiring  spinous  processes  in,  45 
Prepatellar  bursitis,  341 
Progressive  muscular  atrophy,  511 

Erb's  type   of,  512 
Pseudo-muscular  hypertrophy,  507 

attitudes  in,  509 

club-foot  in,  510 

etiology,  507 

mental  defect  in,  509 

pathology,  507 

symptoms,  508 
Psoas  abscess,  26 

Pulmonary    hypertrophic     osteoarthrop- 
athy, 200 

Repair  of  tendons,  397 
Resection  (see  Excision) 
Retropharyngeal  abscess,  25,  28 
Rhachitis,  527 
Rheumatic  gout,  190 
Rheumatism,  193 
Rheumatoid  arthritis,  190 
Rice  bodies,  176 
Rickets,  527 


Rickets,  adolescent,  529 

attitude,  538 

bones,  534 

congenital,  529 

deformities,  533 

diagnosis,  540 

epiphyses  in,  535 

etiology,  529 

head  in,  534,  535 

hydrocephalus  and,  536 

lordosis  in,  535 

paralysis  of,  533 

pathology,  527 

pelvis  in,  538 

phosphorus  in,  543 

prognosis,  542 

spine  in,  537,  542 

symptoms,  533  % 

treatment,  543 
Rizzoli's  osteoclast,  574 
Round  shoulders,  142 

treatment,  148 
Rupture  of  quadriceps  tendon,  352 

Sacro-coccygeal  disease,  379 
Sacro-iliac  disease,  376 
Sarcoma  of  bone,  187 

of  the  spine,  153 
Scapula,  congenital  elevation  of,  593 
School  seats,  118 
Scurvy,  joints  in,  200 
Semilunar      cartilages,    dislocation     of, 
345 

treatment,  347,  351 
Scrofulous  (see  Tuberculous) 
Senile  coxitis,  297 

scrofula,  183 
Sequestra  in  tuberculous  joints.  171 
Short  leg,  597 

Shortening  in  hip  disease,  227,  287 
Shoulder,  bursitis,  364 

Charcot's  disease,  366 

congenital  dislocation,  440 

dislocation  of,  habitual,  308 

epiphysitis,  364 

excision,  367 

gonorrhceal  arthritis,  366 

rheumatism,  365 

synovial  cysts,  366 

synovitis,  363 

teno-synovitis,  364 

treatment  of  diseases  of,  366 

tuberculous  disease  of,  364 


654 


GENERAL   INDEX. 


Spastic  paralysis  488  (see  also  Cerebral 
paralysis) 

gymnastics  in,  502 

tendon  transplantation  in,  504 

tenotomy  in,  503 
Spastic  paraplegia,  488 

torticollis,  581. 
Spinal  arthropathy,  198 

paralysis,  450 
Spine,  ankylosis  of,  149 

angular  curvature  of,  1 

arthritis  deformans  of,  37 

carcinoma  of,  153 

caries  of,  1 

examination  of,  30 

gonorrheal,  148,  151 

hysterical,  36,  61 

malignant  disease  of,  153 

ostitis  of,  6 

osteomyelitis  of,  37 

sarcoma  of,  153 

spondylolisthesis,  156 

sprains  of,  35 

syphilis  of,  155 

tuberculosis  of,  1 

traumatic  spondylitis,  36,  152 

typhoid,  152 

variation  in  length  of,  141 
Spondylitis,  1 

deformans,  37,  148 
Spondylolisthesis,  156 
Spondylose  rhizomelique,  148 
Sternoclavicular  disease,  379 
Sternum,  379 

Subpatellar  bursa,  disease  of,  342 
Subtrochanteric  osteotomy,  276 
Suspension  in  Pott's  disease,  effect  of,  52 
Symphysis  pubis,  disease  of,  379 
Synovial  cysts  of  knee,  340 

cysts  of  shoulder,  366 
Synovitis  of  ankle,  353 

chronic,  165 
dry,  168 
purulent,  167 
serous,  165 
ulcerative,  168 

of  elbow,  370 

of  hip,  296 

of  knee,  337 

of  shoulder,  363 

of  wrist,  373 
Syphilis  and  rickets,  532 

of  bone,  188 


Syphilis  of  spine,  155 
Syphilitic  arthritis,  189 

Tabetic  arthropathy,  198 
Tables  of  height  and  weight,  117 
Talipes  calcaneus,  602 

equino-varus,  380 

equinus,  598 

valgus,  616 

varus,  380 
Taylor  brace,  59 

head  support,  66 

shoe  for  club-foot,  418 
Temperature  in  joint  disease,  23 
Temporomaxillary  articulation,  379 
Tendon  transplantation  in  infantile  pa- 
ralysis, 481 

in  spastic  paralysis,  504 
Tenotomy  in  infantile  paralysis,  485 

in  spastic  paralysis,  503 

of  tendo  Achillis,  395 
Thomas'  collar,  67 

hip  splint,  259 

knee  splint,  319 
Thorax,  distortion  of,  164 
Toe-joints,  diseases  of,  362 
Toes,  contraction  of,  641,  643 
Torsion  in  lateral  curvature,  89 
Torticollis,  579 

acquired,  581 

Buckminster  Brown's  splint,  588 

congenital,  579 

diagnosis,  586 

etiology,  579 

ocular,  581 

operations  for,  588 

pathology,  583 

posterior,  590 

prognosis,  587 

retention  appliances,  591 

spastic,  581 

treatment,  592 

treatment,  587 
Traction  in  caries  of  spine,  43 

in  hip  disease,  248 

in  knee-joint  disease,  325 
Traumatic  spondylitis,  36 
Traumatism  and  joint  disease,  181 
Trigger-knee,  352 

Tuberculosis  of  joints,  pathology  of,  169 
Tuberculous  disease  of  ankle,  354 

of  elbow,  370 

of  hip,  205 


GENERAL   INDEX. 


655 


Tuberculous  disease  of  knee,  308 

of  pelvis,  376 

of  sacro-iliac  joint,  376 

of  shoulder,  364 

of  spine,  1 

of  sternum,  379 

of  tarsus,  354 

of  wrist,  374 
Tumor  albus  (see  Knee) 
Tumors  of  bone,  187 
Typhoid  spine,  152 

Unilateral   atrophy   and   hypertrophy, 
595 


Valgus  shoe,  628 

Varus  shoe,  418 


Weak  ankles,  607 
Weakened  foot,  007 

gymnastics  for,  635 

treatment  of,  027 
Wrist,  arthritis  deformans  of,  373 

congenital  dislocation,  474 

excision,  374 

synovitis,  373 

tuberculous  disease  of,  374 
Wry-neck,  579 


COLUMBIA  I 

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